Medication Intervention in Transitional Care to Optimize Outcomes & Costs for CKD & ESRD

Patients with CKD and ESRD have more co-morbidities, are hospitalized more often and for
longer lengths of stay, and incur greater healthcare costs than patients with other chronic
conditions. Enhanced hospital to home transitional care interventions have been shown to
improve medication information transfer, reduce hospital readmissions, and slow the
progression of declining health in the general population of hospitalized patients. What is
not known is the impact enhanced transitional care can have for a very high-risk population,
such as those with CKD and ESRD. Interventions that prevent or slow CKD progression, i.e.
blood pressure control and intensive glycemic control in patients with diabetes, are all
highly dependent on meticulous medication management.

For hospitalized patients with CKD or ESRD who are transitioning to home, accurate and
comprehensive information transfer is essential to optimal medication management. CKD and
ESRD patients are in critical need of improved transitional care that includes accurate and
comprehensive medication information transfer. The main objective of this application is to
pilot-test the effectiveness of a medication information transfer intervention to improve
clinically-relevant outcomes. To this end, the following Specific Aims will be achieved: 1.
Evaluate the impact of transitional care interventions on acute care utilization following
hospital discharge among patients with CKD or ESRD. 2. Evaluate the impact of transitional
care strategies on management of CKD or ESRD management and complications.

Inclusion Criteria for CKD arm:

1. Hospitalized patients

2. > 21 years of age

3. Diagnosis of CKD stages 3-5, not treated by dialysis

Inclusion Criteria for ESRD arm:

1. Hospitalized patients

2. > 21 years of age

3. Patients treated with hemodialysis or peritoneal dialysis

Exclusion Criteria:

1. Kidney Transplant