Table 2.

Chronic Care Model elements targeted by “Patient Centered Kidney Transitions Care’ intervention

Chronic Care Model Element	Patient-centered Kidney Transitions Intervention Component Addressing Model
Health System Culture	• Prompt providers to engage in patient-centered transitions care • Broadcast patient preferences for kidney failure treatments as advanced directives • Embed Kidney Transitions Specialists into health care team
Clinical Information System	• Kidney Transitions registry • Enable entry and display of patient values and preferences in Electronic Health Record • Enable personalized Kidney Transitions Care planning
Health Delivery System Design	•  Enable education, psychosocial, and biomedical care coordination support
Decision Support	• (For providers): Prompts to engage in shared decision-making and develop plans that are aligned with patients’ preferences • (For patients): Provide resources and support informed shared decision-making
Self-management Support	• Provide self-management education • Build self-management skills through Empowerment Training
Community Resources	• Facilitate patients’ access to clinic and community resources for professional and peer psychosocial support