Care Transitions in Renal Disease Patients

• Conditions: Renal Disease

• Registration Number: NCT01842776
• Lead Sponsor: Fresenius Medical Care North America

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.

Detailed Description

Not available

Study Timeline

• Study Start: 2013-03
• Status Verified: 2013-04
• Study First Submitted: 2013-04-22
• Study First Submitted QC: 2013-04-25
• Last Update Submitted: 2013-04-25
• Study First Posted: 2013-04-30
• Last Update Posted: 2013-04-30
• Primary Completion: 2014-06
• Study Completion: 2014-12

Recruitment & Eligibility

• Status: UNKNOWN
• Sex: All
• Target Recruitment: 3300

Inclusion Criteria

• Chronic hemodialysis patients
• All patients admitted to the hospital during the study period

Exclusion Criteria

• Patients <18 years old

Study & Design

• Study Type: OBSERVATIONAL
• Study Design: Not specified

Primary Outcome Measures

Name	Time	Method
30-day readmission rate	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).

Trial Locations

Locations (1)

Fresenius; 🇺🇸 Franklin, Tennessee, United States