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How The Strive Model Works

Advance Care Planning for CKD Patients: Best Practices Guide

Strive Health

Patients with advanced chronic kidney disease face some of the highest mortality rates among chronic illnesses and carry a heavy symptom burden. Yet utilization of palliative care and advance care planning (ACP) remains strikingly low across nephrology practices.

The gap creates missed opportunities. When nephrology teams start advance care planning early and integrate it into existing workflows, they align treatment with patient values, improve satisfaction and reduce unplanned hospitalizations. 

“Patients with advance chronic kidney disease and those receiving dialysis deserve care that honors their values and priorities,” said Anjali Gupta, M.D., Nephrology Medical Director at Strive Health. “Early advance care planning gives them control over their journey and helps them focus on what matters most in their lives.”

Identify Priority Patients Early  

Nephrology practices achieve the strongest results when they target advance care planning to high-impact populations. Priority patients include those with frequent hospitalizations, ESKD patients with declining functional status or poor quality of life, candidates for optimal starts who elect conservative care and people with advanced heart failure. 

Start these conversations early to create opportunities to align care with patient goals before a crisis forces difficult decisions.   

Augment With Palliative Care  

Palliative care adds a vital layer of support for patients with high symptom burden, frequent hospitalizations or ESKD-related fatigue and distress. It focuses on symptom management, communication and quality of life throughout the ESKD journey, not just at the end of life.

Integrate Into Existing Workflows  

Nephrology practices can incorporate ACP review and palliative care referrals into CKD and dialysis workflows without creating administrative burden. Review ACP status during monthly interdisciplinary team meetings and after each hospitalization to keep care plans updated and relevant.  

Prioritize Patient Voice 

Shared decision-making should guide the conversation, with patients recognized as the experts of their own lives and families engaged as appropriate.  

Key discussion points include what matters most to the patient in their daily life, understanding of current health status, treatment preferences and limits, quality of life priorities and identification of a surrogate decision-maker. 

ACP Drives Better Outcomes and Lower Costs

Targeted, team-based ACP and palliative care discussions do more than show compassion — they drive strategic value. When applied thoughtfully to patients with advanced disease burden or complex needs, they strengthen coordination, reduce unnecessary hospitalizations and align directly with value-based care goals of improved outcomes and lower total cost of care.

Strive Is Here To Help  

Strive Health partners with nephrology practices to implement ACP workflows and provide direct patient support through our social work team. Contact us to learn more about how we support provider partners. 

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Matthew Kerr,

RD, LD

Manager, Dietetics

"Food for your kidneys shouldn't feel like a punishment. I build a nutrition plan around your lifestyle and help you make small changes that stick, not strict rules that don't fit. I'm here with ongoing encouragement, so you don't have to navigate your health journey alone."

Lyndsey Edwards,

LCSW

Licensed Clinical Social Worker

"Navigating health challenges and mental health concerns can feel overwhelming, but you don't have to do it alone. I offer a supportive space to discuss your concerns, understand your care options, and access essential resources so you can make meaningful progress toward your goals and improving your quality of life."

Rhonda Washington,

MSN, CRNP

Nurse Practitioner

"You'll always have someone in your corner who knows your full story. I adjust your medications, order labs and coordinate your care across nephrologists, primary care providers and your wider team to catch problems early. When it's time to weigh treatment options, I walk you through each one, so you choose what's right for you." 

Maya

Ready to Take Charge of Her Health

How Strive Helped
Maya's Strive Health team helped her understand her new diagnoses by sharing Spanish-language resources and building a plan for what comes next. She even met with a Strive dietitian who created a personalized nutrition plan. Maya now feels confident and in control of her health. 
 
The story presented is a composite based on real patient experiences. No actual patient names or identifying details are used. 

James

Determined to Stay on Track

How Strive Helped
James’ Strive nurse practitioner helped him coordinate home delivery for his medications, so he never misses a refill. Together they built a simple, realistic plan that connected James to a cardiologist and kept his whole care team informed and on track. 

The story presented is a composite based on real patient experiences. No actual patient names or identifying details are used.   

Patricia

Advanced Care for Advanced Needs

How Strive Helped
Patricia's Strive social worker helped her access financial assistance programs, find resources to afford her medications and connect to community support. Now, she has a team in her corner, and she no longer faces her health journey alone. 

The story presented is a composite based on real patient experiences. No actual patient names or identifying details are used.

Betsy Gonzales,

BSN, RN

RN Care Manager

"There is always something we can do. I know that firsthand as a former dialysis patient. Together we set clear goals for your blood pressure, hydration and diet. I treat every small win like a big one. I'm not just your clinician. I'm an ally who understands the journey."