Integrated primary and secondary care optimizes the management of people with CKD—the LUCID project

Background Early diagnosis, risk stratification and medication optimization are essential to improve the management of chronic kidney disease (CKD) and other long-term conditions. The introduction of Integrated Care Systems (ICS) in England provides the opportunity to revolutionize the management of these conditions. Annual National Health Service kidney disease costs are ∼£6.4 billion. Methods We designed, piloted and implemented at scale an ICS-level virtual care programme for CKD, the ‘Leicester, Leicestershire, and Rutland Chronic Kidney Disease Integrated Care Delivery Project’ (LUCID), based on the principles of patient and professional education, early disease identification, medicines optimization and disease surveillance. Results In April 2022, virtual multidisciplinary team (MDT) meetings were piloted in Leicester, Leicestershire and Rutland, UK. Since April 2023 virtual MDT meetings have been available to all general practices in Leicester, Leicestershire and Rutland, representing a population of approximately 1.2 million people. As of 31 March 2024, general practices representing an estimated population of 700 000 (58.3%) were participating in the LUCID programme. Some 1085 consultations took place for 821 patients, 590 (54.4%) of which were medicines optimization consultations. Conclusions LUCID may represent an efficient and cost-effective model to deliver patient and professional education, medicine optimization and risk stratification for people living with CKD at an ICS-wide population level. This model may be adaptable for other long-term physical and mental health conditions.