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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 real life and help you make small changes that stick, not stark 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

Whatever weighs on you, you don't have to carry it alone. I offer a space to talk through fear, grief, stress and uncertainty without judgment, then connect you to resources and support that fit your needs. In every care decision, your voice matters most, and I make sure it's heard.

Rhonda Washington, MSN, CRNP

Nurse Practitioner

You'll always have someone in your corner who knows your full story. I 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 advocate connected her with a Strive dietitian who helped her build a personalized nutrition plan for her blood sugar and kidney health. With education available in the language she needs, Maya feels empowered to take control of her health.

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, created a simple plan that helps James with both his practical needs and his health needs. James now sees a Cardiologist, his care team is kept informed, and he feels more in control.

Patricia

Advanced Care for Advanced Needs

How Strive Helped
Her Strive social worker helped her access financial assistance programs, navigate her benefits and connect to community support. Patricia has a team in her corner now, and she no longer faces her health journey alone.

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.