Examination of the patient experience within our unit, from pre dialysis through to establishment of dialysis in the community identified that the care was fragmented. To improve patient care, a change process was initiated. Four home care teams comprising three qualified nurses and one renal care assistant were established with each team responsible for a caseload of patients within a specified geographical location. To measure the impact on the patient, 100 questionnaires were circulated after twelve months. Results from 60 patients showed 76% of pre dialysis patients and 80% of dialysis patients were very satisfied with the change process. The main advantage of this change for the patient is that they are in a continuous supportive cycle for all their non-inpatient care throughout their replacement therapy. We conclude that patient focused care is essential and should be a transition catalyst in a change resistant environment.
Renal rehabilitation is complex; efficient goal-planning is needed to ensure that the process is as effective as possible. Through the use of a case study, this article assesses the feasibility and usefulness of 'life goals' questionnaires for older people within a renal setting. The development and use of a patientcentred goal-planning approach to renal rehabilitation is recommended.
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