Care Transitions in Renal Disease Patients
| Status: | Completed |
|---|---|
| Conditions: | Renal Impairment / Chronic Kidney Disease |
| Therapuetic Areas: | Nephrology / Urology |
| Healthy: | No |
| Age Range: | 18 - Any |
| Updated: | 4/2/2016 |
| Start Date: | March 2013 |
| End Date: | December 2014 |
| Contact: | Rebecca L Wingard, RN, MSN |
| Email: | rebecca.wingard@fmc-na.com |
| Phone: | 615-567-4846 |
The goal of this pilot is to reduce the 30-day hospital readmission rate for dialysis
patients. It is a quality improvement project that consistent of 4 "tracks." Tracks 1 & 2:
Implement use of checklists of activities for staff to complete when patients are admitted
to the hospital, and post-hospitalization with emphasis on fluid assessment, nutrition
management, patient coaching, and communication between institutions. Track 3: Work with
physicians to develop process to individualize post-hospitalization dialysis orders and
improve medication reconciliation. Track 4: Use a renal Care Transitions Case Manager to
follow patients in the hospital and 30 days post-hospitalization to facilitate care and
patient coaching.
patients. It is a quality improvement project that consistent of 4 "tracks." Tracks 1 & 2:
Implement use of checklists of activities for staff to complete when patients are admitted
to the hospital, and post-hospitalization with emphasis on fluid assessment, nutrition
management, patient coaching, and communication between institutions. Track 3: Work with
physicians to develop process to individualize post-hospitalization dialysis orders and
improve medication reconciliation. Track 4: Use a renal Care Transitions Case Manager to
follow patients in the hospital and 30 days post-hospitalization to facilitate care and
patient coaching.
Inclusion Criteria:
- Chronic hemodialysis patients
- All patients admitted to the hospital during the study period
Exclusion Criteria:
- Patients <18 years old
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