Care Transitions in Renal Disease Patients
Trial Snapshot
- Phase
- Not Applicable
- Enrollment
- 3,300
- Locations
- 1
- Primary Endpoint
- 30-day readmission rate
Study Overview
Brief Summary
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.
Study Design
- Study Type
- Observational
- Observational Model
- Cohort
- Time Perspective
- Prospective
Eligibility Criteria
- Ages
- 18 Years to — (Adult, Older Adult)
- Sex
- All
- Accepts Healthy Volunteers
- No
Inclusion Criteria
- •Chronic hemodialysis patients
- •All patients admitted to the hospital during the study period
Exclusion Criteria
- •Patients <18 years old
Outcomes
Primary Outcomes
30-day readmission rate
Time Frame: Participants will be followed for the duration of each hospital stay and 30 days post-hospitalization, for an expected average of 37 days.
Number of hospitalizations that occur within 30 days after discharge from an initial index hospitalization (convert to percentage of 30-day readmissions).
Secondary Outcomes
No secondary outcomes reported