Multiple Chronic Conditions | Resource Center

The APOL1 gene is recognized as a kidney risk gene. APOL1-mediated kidney disease is a rapidly progressive form of proteinuria kidney disease. Although this gene is autosomal recessive the risk comes from the genotype of both parents. Compared with other chronic kidney disease patients, those of African ancestry with a confirmed APOL1 gene variant progress to dialysis 9 to 12 years earlier. APOL1-mediated kidney disease is often associated not only with proteinuria but also with a rapid decline in eGFR, earlier onset of kidney disease (including adolescence), and leads to a mean age of kidney failure in the U.S. of 45 years. Patients are often asymptomatic. Richard Knight, co-founder of the APOL-1 Alliance (https://apol1alliance.org/), provides a patient perspective on this condition.

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Dr. Jordan Yakoby discusses how these newly established recommendations provide a structured, evidence-informed framework for delivering neurocritical care remotely. Designed for hospitals and emergency departments without continuous neurointensivist coverage. He reviews the 13 recommendations from the society that outline both minimal and optimal standards to ensure critically ill neurologic patients receive timely, expert-driven care regardless of geographic limitations.

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Rosa Hart, a stroke certified registered nurse with the American Association of Neuroscience Nurses, describes new updates from the America Heart Association and the American Stroke Association’s January release of the 2026 Guideline for the Early Management of Patients with Acute Ischemic Stroke. This guideline replaces the 2018-2019 guideline and updates. In the same month the Centers for Disease Control and Prevention identified the top 5 causes of mortality in the United States and identified stroke as the 5th cause of death in the country. Stroke contributes to over 162,000 deaths annually and accounts for approximately 1 in 6 deaths from cardiovascular disease. It is one of the leading causes of long-term disability, occurring on average every 40 seconds.

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This Podcast highlights the rural healthcare center established by Northern Michigan University (NMU) and its impact on the rural population who reside in the upper peninsula of Michigan. Former Director James K. Haveman of the Michigan Department of Community Health under two Governors, and Elise Bur the Director of the Center discuss the evolution of the NMU Rural Healthcare Center and its impact on providing determinants of health to a unique patient population.

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Cheryl Phillips, M.D, AGSF, is the senior program consultant for the John A Hartford Foundation’s Age-Friendly Health Systems initiative and discusses the 4Ms. What Matters, Medication, Mentation and Mobility and how these concepts interface with person-centered care planning for persons with and at risk for multiple chronic conditions. Dr. Phillips describes the administration’s policy changes with the Agency for Healthcare Research and Quality and how the John A. Hartford Foundation will continue to promote person-centered care for the nations aging population

The Centers for Medicare & Medicaid Services released a new Age Friendly Hospital Measure  designed to improve the care and outcomes of older hospitalized adult patients.
https://www.facs.org/quality-programs/accreditation-and-verification/geriatric-surgery-verification/cms-age-friendly-hospital-measure/

Institute for Healthcare Improvement Patient and Family Resources on Age-Friendly Care https://www.ihi.org/library/tools/patient-safety-essentials-toolkit

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In this edition of the MCCRC Podcast, Dr. Kim Kuebler sits down with Richard Knight to discuss the Patient Perspective for those with Kidney Disease.

Hear Richard's key take away’s, specific information that would have helped him to better understand how his hypertension impacted upon his kidney function, talking about the missing links in the collaborative medical management of patients with kidney disease, and much more!

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Arlene Bierman MD, MS, Brittany Watson MD, MPH and Jane Pederson MD, MS discuss the recent JAMA online publication Person-Centered Care Planning for People Living with or at Risk for Multiple Chronic Conditions. This paper describes a qualitative study using theme analysis from responses following a Request for Information (RFI) published in the Federal Register soliciting input on PCCP, posted by the Agency for Healthcare Research and Quality (AHRQ) in 2022. Responses were analyzed between January 2023 and February 2024.

The researchers identified 9 themes: (1) suboptimal quality of care; (2) person-centered, goal-concordant care; (3) multidisciplinary team–based care and care coordination; (4) prevention across the life course; (5) digital health solutions; (6) workflow; (7) education and self-management support; (8) payment; and (9) achieving community, health system, and payer goals.

The information collected from this study are used to gain momentum in the AHRQ’s initiative on Person-Centered Care Planning for People with MCC. This data was used to solicit input from multidisciplinary experts, patients and policy stakeholders at the recent AHRQ Summit to determine next steps in promoting comprehensive care for the nation’s largest patient population – those living with MCC.

LINK TO FULL ARTICLE: https://www.nursingoutlook.org/article/S0029-6554(24)00166-0/abstract?dgcid=raven_jbs_etoc_email

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A link to the slides mentioned in the podcast: https://hcanys.org/doclink/kuebler-medication-safety/eyJ0eXAiOiJKV1QiLCJhbGciOiJIUzI1NiJ9.eyJzdWIiOiJrdWVibGVyLW1lZGljYXRpb24tc2FmZXR5IiwiaWF0IjoxNzMzNDIwOTE0LCJleHAiOjE3MzM1MDczMTR9.Xg5H1OS1UAio4gUrdriWHmecDx9uMOC-ZmB2Y-Rv9I8

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In the sixth edition of the MCCRC Podcast, Dr Kim Kuebler sits down with Dr. Eduardo Bruera to discuss palliative care in and how it is being used in the primary care setting for those patients living with non-reversible, symptomatic chronic conditions.

Here is a link to the reference Dr. Bruera used in this podcast: https://www.nursingoutlook.org/article/S0029-6554(24)00166-0/abstract?dgcid=raven_jbs_etoc_email 

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In the fifth edition of the MCCRC Podcast, Dr. Kim Kuebler sits down with Dr. Paul Ciechanowski talks about the benefits of integrated behavioral health models in primary care, why integrated care is a preferable model to hiring psychiatrists or social workers as part of a co-located model, and much more.

Here are links to the references Dr. Ciechanowski used in the podcast:

Clinical inertia:

https://escholarship.org/content/qt7fd7r9r5/qt7fd7r9r5.pdf

Two clinical trials that support collaborative care by research groups:

https://jamanetwork.com/journals/jama/fullarticle/198486

https://www.nejm.org/doi/full/10.1056/NEJMoa1003955

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