Health services and clinicians can use these service and organisational models, and clinical priorities to support the quality of life and wellbeing for people living with chronic kidney disease.
Chronic kidney disease causes a slow loss of kidney function, including the ability to remove waste and maintain normal blood pressure, water and electrolyte balance. Chronic kidney disease has a high symptom burden and is associated with other chronic diseases (such as diabetes) and limited lifespan.
The NSW renal supportive care model is an integral part of renal services. It supports patients' quality of life and wellbeing while living with chronic kidney disease.
Renal supportive care involves an interdisciplinary approach, integrating renal medicine and palliative care services, and encompassing advance care planning and end of life care. Renal supportive care has the following features:
- The renal team responsible for long-term treatment remains with the patient from chronic kidney disease diagnosis to the end of life.
- The nephrologist provides local leadership for the service.
- The model is primarily nurse-coordinated, supported by a dietitian, social worker and a physician or medical consultant (where available).
- Care involves physical, psychological, emotional and spiritual dimensions and support for families and carers.
- Care is provided as close to home as possible, considering patient preferences.
- Patient-reported experience and outcome measures are collected and acted upon.
In 2015/16, NSW Health provided recurrent funding for the statewide rollout of the Renal Supportive Care Model in a networked approach.
Service model
Published: August 2018. Next review: 2028.
Care for patients with chronic or end stage kidney disease (mainly stage four and five), who are:
- deciding on a treatment pathway
- being managed conservatively
- receiving renal replacement therapies (dialysis or transplant)
- withdrawing from dialysis.
For clinicians and services
What to consider
Read about the 4 clinical priority areas to manage chronic kidney disease:
- Share decision-making: patients, families and carers discuss with the renal multidisciplinary team: their treatment options, expected progression of the disease and support available.
- Refer to renal supportive care service: patients with advanced chronic kidney disease who have symptoms and suffering should be referred to a renal supportive care service.
- Minimise patient suffering: the multidisciplinary team draws on PRMs and clinical judgment to tailor treatment to relieve symptoms and suffering.
- Provide ongoing supportive care: integrated, coordinated care monitors changes in symptom burden over time and engages with patients, families and carers to revisit treatment options.
How to improve
Explore options for different organisational models to tailor clinical services for your local requirements:
- Coordinated multidisciplinary model
- Outreach model based on a renal supportive nurse
Case studies
- Multidisciplinary clinic (NBMLHD)
- Multidisciplinary clinic (MNCLHD)
- Nurse-led renal supportive care service (CCLHD)