Ending Disparities in CKD in Illinois: Roadmap Commitment Form

Acknowledgment and Organization Plans

*By filling out this document, you acknowledge you are authorized to make commitments on behalf of your organization.

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* 1. First and last name

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* 2. Email

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* 3. Organization Affiliated With

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* 4. Role/title

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* 5. Please choose the answer that best represents your organization's participation in the recommendations discussed at the NKFI Leadership Summit.

My organization will participate in the recommendations discussed at the Leadership Summit

My organization is interested in participating in the recommendations discussed at the convening and would like to identify ways we can be most impactful.

My organization cannot participate in the recommendations discussed at the Leadership Summit at this time, please reach out to me at a later date to discuss opportunities in the future.

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* 6. What recommendations will you participate in? (select all that apply)

Expand engagement with diverse stakeholders in the community to develop awareness messages and CKD educational content.

Utilize the Collective Impact model to engage a wide group of partners in the implementation of a CKD awareness campaign strategy.

Partner with community organizations to develop a cadre of trusted CKD ambassadors to disseminate CKD information and resources.

Increase primary care team knowledge and capacity to support CKD testing, diagnosis, and management.

Build Capacity and Opportunities to Integrate Community Health Workers into primary care settings to support care coordination, patient education, and self-management.

Expand engagement with “non-traditional”, community-based care providers including faith-based organizations, pharmacies, community centers, and food banks to support CKD testing and management.

Develop and deploy tools to optimize the EMR for CKD testing, diagnosis, and management.

Develop a workgroup to create a CKD data story/dashboard for Illinois.

Demonstrate Return-on-Investment for earlier detection and management of CKD.

Increase awareness and prioritization of quality measures that encourage CKD testing and early diagnosis.

Advance funding and reimbursement models to support primary care capacity, especially to support deployment of CHWs or others to care coordination and patient support.

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* 7. I am prepared to help with the above projects as a…

Leader on a project

Work within a designated task force

Committed team member

Connector or convener (set up meetings with partners)

Funder or financial supporter

Able to help minimally, but enthusiastically

Ending Disparities in CKD in Illinois: Roadmap Commitment Form

Question Title

* 1. First and last name

Question Title

* 2. Email

Question Title

* 3. Organization Affiliated With

Question Title

* 4. Role/title

Question Title

* 5. Please choose the answer that best represents your organization's participation in the recommendations discussed at the NKFI Leadership Summit.

Question Title

* 6. What recommendations will you participate in? (select all that apply)

Question Title

* 7. I am prepared to help with the above projects as a…

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* 8. Please explain further.