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Ontario Renal Plan

The Ontario Renal Plan 2015–2019 is our second comprehensive strategy to guide the delivery of kidney care services in Ontario.

The plan lays out 3 main goals. The underlying philosophy of the goals is a shift away from traditional provider-driven care towards a new model focused on people with chronic kidney disease and their families.

Empower and support patients and family members to be active in their care.

By 2019

  • Patients and families will be empowered to make shared decisions with their healthcare team across the kidney care journey.
  • Patient and family feedback will drive regional and provincial quality improvement.
  • Patients and families will be engaged in the planning and evaluation of kidney care services.

Strategic Objectives

  • Engage and educate patients and families to make shared decisions with their multidisciplinary care team. 
  • Support and enable patients and healthcare professionals in developing a self-management approach to chronic kidney disease. 
  • Use patient-reported outcomes to drive improvements in kidney care. 
  • Collaborate with patients and families on the design, delivery and evaluation of kidney care services. 

Initiatives

  • Develop and implement standardized tools that enable shared decision-making, encourage self-management and jointly establish goals of care.
  • Partner with regional and provincial organizations to strengthen and broaden the use of peer-to-peer support. 
  • Collect and report patient experience and outcome measures for targeted quality improvement.
  • Develop formal opportunities for patients and family members to be involved in kidney care system initiatives.

Integrate patient care throughout the kidney care journey

By 2019

  • Hospitals and primary care providers will have the tools they need to reduce the incidence of avoidable harm, including acute kidney injury, in people with, or at risk of, chronic kidney disease (CKD). 
  • Primary care providers will have timely access to the tools and support they require to identify and manage care for people with early CKD. 
  • Patients transitioning from primary care to nephrology will have timely access to appropriate pre-dialysis care. 
  • Patients will receive person-centred and well-coordinated palliative care. 
  • Patients will experience an easy-to-navigate pre- and post-transplant care journey.

Strategic Objectives

  • Define care expectations, best practices and accountabilities to optimize the delivery of integrated and coordinated person-centred care. 
  • Ensure partnerships with provider agencies are in place to facilitate seamless patient care transitions. 
  • Support primary care providers in the early identification and management of people with CKD to reduce the risk of end-stage kidney disease. 
  • Establish an integrated process for the early identification and management of people with CKD who would benefit from a palliative approach. 
  • Enhance access to, and improve patients’ experiences of, transplantation.

Initiatives

  • Explore and develop safety initiatives and tools to prevent avoidable harm, including acute kidney injury, in primary care and hospital settings.
  • Develop and implement tools to assist with the early identification and management of people with CKD in primary care. 
  • Establish provincial standards and accountabilities with Regional Renal Programs to streamline the transition between primary care and nephrology, for people with CKD at risk of progression to end-stage kidney disease. 
  • Define and implement a model of care that supports comprehensive delivery of palliative care for patients. 
  • Adopt and adapt provincial frameworks and standards for palliative care of people with CKD.
  • Identify and optimize the care pathway for patients navigating the transplant process, including pre- and post-transplant, in collaboration with Trillium Gift of Life Network. 
  • Ensure the necessary infrastructure is in place across the provincial network for kidney care programs to support pre- and post-transplant care in collaboration with Trillium Gift of Life Network.

Improve patients' access to kidney care

By 2019

  • People living in rural and remote Ontario will have improved access to care solutions that allow them to remain in their communities. 
  • Culturally and geographically appropriate kidney care will be available to First Nations, Inuit and Métis people. 
  • Clinical, economic and cultural barriers to kidney care at home and in long-term care will be addressed. 
  • A community-first approach to kidney care will be adopted in Ontario. 
  • Patients will have timely access to vascular and peritoneal access services. 
  • Models of care for the delivery of safe, high-quality, timely and accessible kidney care will be implemented, monitored and evaluated.

Strategic Objectives

  • Identify barriers to accessing kidney care and develop person-centred solutions.
  • Establish a community-first approach to kidney care.
  • Ensure infrastructure and services are in place to enable home dialysis.

Initiatives

  • Adapt tools and approaches to improve access to kidney care for First Nations, Inuit and Métis and rural and remote communities.
  • Develop and implement a flexible policy framework for a community-first approach to kidney care.
  • Enhance system capacity for optimal and timely vascular and peritoneal access. 
  • Implement models for the delivery of safe, high-quality and accessible care to people with acute kidney injury, chronic kidney disease and end-stage kidney disease; this includes people requiring specialized care such as those with complex glomerular disease and those with kidney disease during pregnancy.

The second Ontario Renal Plan 2015–2019 emphasizes partnerships between patients and their healthcare teams, among healthcare professionals and between agencies. These collaborations make sure we are all accountable and supported to deliver the best care possible.

Driving Person-Centred Care

In this video, learn how the Ontario Renal Plan encourages people to be more active in their care and fully participate with their healthcare teams in making choices.

Contributors

The Ontario Renal Plan belongs to all Ontarians whose lives are affected by chronic kidney disease. In creating it, we collaborated and consulted extensively with more than 260 participants, including:

  • people with chronic kidney disease and their families
  • healthcare professionals
  • nephrologists
  • renal program administrators
  • regional and provincial partners