Bridging the Gap in Rural Kidney Care

Social drivers of health and community-driven solutions for CKD

Rural communities, defined as any population, housing, or territory not located within an urban area,¹ have a high prevalence of chronic kidney disease (CKD). Despite increasing awareness of health disparities, residents of rural areas continue to face numerous social barriers that limit access to high-quality kidney care.²

Health disparities are closely connected to social drivers of health, which act as “upstream” factors that influence healthcare access and chronic disease outcomes. Social drivers of health—also referred to as social determinants of health—include factors such as income, food security, education, and access to healthcare. The term social drivers of health is increasingly preferred because it emphasizes environmental and social conditions as active forces that can be modified, whereas determinants may imply fixed or less modifiable factors.

Several social drivers of health including limited access to nephrology care, housing instability, unreliable transportation, safety concerns, food insecurity, and financial hardship, significantly affect individuals with CKD. Because of a shortage of kidney specialists in rural areas, individuals may experience delayed diagnosis and treatment of CKD, which increases the risk of disease onset and accelerates disease progression. These delays can lead to higher rates of comorbidities, lower survival rates among patients receiving dialysis, and a reduced likelihood of being wait-listed for kidney transplantation.³

Challenges Related to Dialysis

Another major concern is the limited number of dialysis centers in rural regions, even as the incidence of end-stage kidney disease (ESKD) continues to rise in these communities. Patients may face additional barriers to receiving dialysis, including workforce shortages leading to closures of healthcare facilities, high transportation costs, and lack of adequate health insurance coverage.

Compounding these challenges is the difficulty dialysis facilities face in recruiting and retaining qualified staff. Although dialysis centers experienced growth prior to 2023, more centers began closing rather than opening after that time.⁴ Several factors contributed to this shift, including later initiation of dialysis therapy, which reduced patient volume, and persistent workforce shortages.

These challenges are particularly concerning because stable relationships between dialysis staff and patients are essential for delivering high-quality care. When dialysis facilities close, patients must travel longer distances to receive treatment, creating additional burdens and potentially worsening health outcomes.⁵ Home dialysis therapies, such as in-home hemodialysis and peritoneal dialysis, may provide alternative treatment options for patients in rural communities. However, adoption of these therapies remains limited due to infrastructure barriers, workforce limitations, and insufficient patient support systems.³ Given these challenges, the kidney care community must work collaboratively to address the growing crisis of limited access to high-quality kidney care in rural populations.

Engaging With Community

One promising strategy is the co-creation of a kidney care model in partnership with community stakeholders. Co-creating a model of kidney care with community partners may be an effective way to ensure that interventions are culturally appropriate, accessible, and responsive to the unique needs of rural populations. Community engagement should begin with listening to residents and identifying nontraditional locations for outreach that promote kidney health awareness and prevention.

For example, I participate in a community-based interdisciplinary group composed of pastors, social workers, business leaders, health professionals, and nursing faculty from a local university. This group meets weekly to discuss the needs of the rural community and develop outreach initiatives. The success of this collaborative effort has been reflected in increased community awareness and health-seeking behaviors related to chronic conditions such as kidney disease, diabetes, hypertension, mental health disorders, and dementia. Through networking and ongoing assessment of community needs, the group has been able to implement initiatives that support improved health outcomes in the rural community.

Outreach events have been hosted in community settings such as libraries, churches, and golf courses. However, research suggests that other community locations—such as laundromats, barbershops, and fire stations—can also serve as effective venues for health outreach because they are trusted and frequently visited spaces within the community.⁶ Partnerships like these allow healthcare professionals to think creatively and identify the most effective environments for community engagement.

Programs to Bridge the Care Gap

Developing a kidney care model that incorporates social drivers of health is critical for improving outcomes among individuals with CKD. Effective programs should prioritize awareness, prevention, early detection, and strategies to slow disease progression, while also ensuring that these services are supported through sustainable reimbursement structures. Telemedicine may also play an important role in expanding access to nephrology expertise for patients living in rural areas. In addition, collaboration with primary care professionals—who deliver most healthcare services in rural communities—has demonstrated promising results.

One example is the Kidney Coordinated HeAlth Management Partnership (K-CHAMP), an electronic health record–based population health management approach designed to improve CKD care within primary care settings.⁷ This program uses electronic health record data to identify high-risk patients who are not currently receiving nephrology care. Identified patients are offered consultations with nephrologists and receive kidney disease education from nurses, while primary care professionals receive additional pharmacy support. The program has been successful in strengthening collaboration between primary care and nephrology professionals and promoting proactive care for patients with CKD. Notably, this approach has demonstrated potential for slowing CKD progression by improving early intervention and care coordination.

Programs such as K-CHAMP highlight the importance of integrating population health strategies, interdisciplinary collaboration, and technology to improve CKD outcomes in rural communities. Expanding similar initiatives could increase the implementation of preventive strategies, improve timely referrals to nephrology specialists, and ultimately reduce the risk of progression to ESKD and the need for dialysis. Bridging the gap in rural kidney care through community-driven solutions creates a pathway for addressing social drivers of health among individuals with or at risk for CKD.

The opinions expressed in this column are the contributor’s own and do not represent those of Nephrology Times.