RESUMO
BACKGROUND: People with chronic kidney disease are often multimorbid and have complex psychosocial needs. For health professionals to deliver holistic, person-centred care to individuals and their carers living with this multifaceted disease, they are required to communicate complex information and problem solve in a multifactorial health and disease context. OBJECTIVES: To explore the perspectives and experiences of tertiary care multidisciplinary team members and primary care providers of health care to people with chronic kidney disease; identify opportunities to innovate and improve the coordinated delivery of health services. DESIGN: The qualitative study design used purposive sampling to recruit 39 health professionals, working in the primary and tertiary sector in a regional Australian health district. Participants included general practitioners, renal and general practice nurses, dietitians, nephrologists and social workers. APPROACH: The data were collected through semistructured interviews and analysed using a relativist ontological position and directed content analysis approach. Analysis of interviews was undertaken by three independent researchers and key themes were derived via consensus. FINDINGS AND CONCLUSIONS: A common goal to deliver person-centred individualised care was evident among health care professionals. However a deficit in shared understanding of the disease within and between disciplines was identified. The complex nature of chronic kidney disease requires up-skilling of health professionals to ensure patient education is targeted to individual health contexts and motivates self-management. Improved communication and comprehension might best be achieved across disciplines with an integrated approach to delivery of primary health care to individuals living with early-stage kidney disease.