based care, patient education, community outreach, and tracking process and outcome data, the revised standards included: • Routine laboratory reporting of GFR in the electronic medical record. • Annual monitoring of urine albumin excretion. • Prescription of angiotensin converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARB). To improve diabetes care, IHS also developed clinical education programs and tools, culturally relevant patient education materials and electronic medical record-based population management tools. With these efforts, the IHS was able to achieve a 54 percent decrease in age-adjusted incidence of diabetes-related ESRD for patients with well-documented socioeconomic disparities, including poverty, limited health care resources and disproportionate burden of comorbidities (Bullock et al., 2017). How This Guide Is Organized This guide is written for primary care practice teams and is intended to raise awareness of disparities in CKD and improve the care of vulnerable patients with CKD, and suggests possible approaches to improve the care of vulnerable patients with CKD. It is divided into the following sections: • Summary. • Approaches to Identifying Chronic Kidney Disease. • Approaches to Treatment and Monitoring of CKD Progression. • Approaches to Centering Care on the Patient. Introduction Page 9 of 19 April 2021 Each of the topical sections in the guide explains the importance of the issue and describes potential interventions that primary care practice teams can take to address disparities in care. The Suggested Steps and Resources sections include links to available resources. Existing resources are paired with suggested action steps and are categorized by type (informational materials, practical tools, training materials) and format (CKD tracking tool, letter template, mobile app, online calculator, pamphlet/handout, reference material, referral form, video, webpage). Clinicians and their teams can use this guide to educate themselves, encourage the development and use of protocols to identify people with CKD, monitor progress, connect patients to appropriate resources and refer those who need specialty care. Approaches to Identifying Chronic Kidney Disease Page 10 of 19 April 2021 Approaches to Identifying Chronic Kidney Disease Why Is It Important to Identify Chronic Kidney Disease? Why Is It Important to Identify Chronic Kidney Disease? Racial and ethnic minorities are more likely to progress from CKD to renal failure than their non-Hispanic white counterparts. Beyond kidney failure, CKD progression has other consequences, such as anemia, hypertension, hypoglycemia, mineral and bone disturbances, cardiovascular disease, polypharmacy, medication side effects and death. Most CKD is a long-term consequence of difficult-to-control diabetes and hypertension, conditions that are more common among racial minorities and low-income populations.