Care Transitions in Renal Disease Patients (CT)

Fresenius Medical Care (FMC)

Status: Unknown

Conditions: Renal Disease

Study type: Observational

Funder types: Industry

Identifiers

NCT01842776

20129159

Details and patient eligibility

About

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.

Enrollment: 3,300 estimated patients

Sex: All

Ages: 18+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

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

Exclusion criteria

• Patients <18 years old