Overlooked Care Transitions

Erickson, Kevin F.; Tamura, Manjula Kurella

doi:10.2215/cjn.00220115

Cited by 7 publications

(8 citation statements)

References 8 publications

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“…As evidenced by a rate of 30 day re-hospitalization that is double that of the general medical population, the current state of post-hospital discharge care for patients with ESRD remains suboptimal [ 4 , 7 , 21 ]. Interventions specifically designed to improve this period of patient vulnerability remain sparse.…”

Section: Discussionmentioning

confidence: 99%

A Virtual Ward for Home Hemodialysis Patients – A Pilot Trial

Raphael

Nadeau‐Fredette

Tennankore

et al. 2015

Can J Kidney Health Dis

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BackgroundPatients with end-stage renal disease (ESRD) have a high rate of hospitalization and are prone to care gaps that may occur during the transition from hospital to home. The virtual ward (VW) is an innovative model that provides short-term transitional care to patients upon hospital discharge. The VW may be an effective intervention to address care gaps.ObjectivesThe primary objective of the pilot study was to assess the feasibility and practicality of implementing the Home Dialysis VW (HDVW) on a broader scale.DesignThe HDVW Pilot Study enrolled home hemodialysis patients following one of four inclusion criteria: 1. Discharge from hospital, 2. Completion of an in-hospital medical procedure, 3. Prescription of an antibiotic, 4. Completion of home hemodialysis training. Patients were followed in the HDVW for 14 days and during this time were assessed serially with a clinician-led telephone interview for one of three transitional care gaps: 1. Requirement for change in hemodialysis prescription, 2. Requirement for coordination of follow-up care, 3. Requirement for medication change.SettingThe study was conducted in Toronto, Ontario, Canada at a quaternary care academic teaching hospital from 2012–2013.PatientsThis study included 52 HDVW admissions among 35 patients selected from the existing home hemodialysis program.MeasurementsThe primary outcome was the identification of the number of care gaps at each HDVW admission. Secondary outcomes included the identification of potential predictors of care gaps and description of clinical adverse events following HDVW admission (readmissions, emergency department visits, unplanned visits to the home hemodialysis in-center).ResultsThe implementation and execution of the HDVW Pilot Study proved to be technically feasible and practical. A care gap was identified in 35 (67 %) of the HDVW admissions. In total, the cohort experienced 85 care gaps. There were no baseline demographic characteristics predictive of experiencing a care gap. In the total cohort observed for 2912 patient days, there were 9 readmissions, 13 visits to the emergency department, and 7 unplanned visits to the home hemodialysis in-center unit.LimitationsThe results of this study are limited by the small study size and single-center experience.ConclusionThe implementation of a virtual ward for home hemodialysis patients is practical, feasible and identifies many care gaps which have the potential to result in subsequent adverse events. A larger, multi-center prospective clinical trial is justified to identify if the HDVW can prevent adverse events among home dialysis patients.

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Section: Discussionmentioning

confidence: 99%

A Virtual Ward for Home Hemodialysis Patients – A Pilot Trial

Raphael

Nadeau‐Fredette

Tennankore

et al. 2015

Can J Kidney Health Dis

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“…Adding extra visits is not enough; physicians have to weigh the needs of their patients against unnecessary procedures . The balance has to be set with overall outcomes in mind.…”

Section: Strategies To Mitigate Future Hospitalization In Patients Onmentioning

confidence: 99%

“…108,112,113,116,149,151,164,165 Adding extra visits is not enough; physicians have to weigh the needs of their patients against unnecessary procedures. 170 The balance has to be set with overall outcomes in mind. Prescriptions for dialysis elements should be adjusted constantly with chronic volume goals, malnutrition/inflammation indices, and quality of life, in mind ( Table 1).…”

Section: Identifying High-risk Patientsmentioning

confidence: 99%

Decreasing hospitalizations in patients on hemodialysis: Time for a paradigm shift

Golestaneh

2018

Seminars in Dialysis

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Hospitalizations drive up to 35% of the astronomical costs of care for patients on hemodialysis and are associated with poor outcomes. We describe outpatient care-sensitive categories of hospitalization risks in an effort to engage stakeholders and patients, as stakeholders, in mitigating hospitalizations. These categories include: (1) fluid (interdialytic weight gain (IDWG) and chronic volume status), (2) infection (vascular access and malnutrition/inflammation resilience), and c) psychosocial (poor social support, poor self-efficacy, and mood disorders) risks. Barriers to improving hospitalization outcomes, especially as they relate to above risk categories, exist at multiple stakeholder levels and include: (1) dialysis facilities (strict shift changes, personnel challenges), (2) nephrologists (static dialysis prescriptions and protocols based on dialysis facility metrics), and (3) patients (lack of engagement and self-efficacy). System-level elements, such as payment models, help to propagate these barriers. In this article, we seek to shift the care paradigm discussion to patient trajectories and long-term outcomes, and to active engagement of patients as self-managers, through which we hope to impact on high inpatient resource utilization. We will also focus attention on the complex interplay of practices that have become acceptable care structures, but that may be deleterious to outcomes. Only after thorough consideration of these topics can we hope to impact on this important problem.

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“…Thirty to 35% are re-hospitalized within 30 days of discharge compared to 18% of the general Medicare population [ 1 – 4 ]. In response to this crisis, the Centers for Medicare Services (CMS) has made 30-day hospital readmission a dialysis facility quality metric [ 5 ]. Patients on hemodialysis are high utilizers of inpatient services because of extremely complex clinical needs in addition to psychosocial needs that are amplified in the face of demanding treatment schedules and restrictive lifestyle requirements [ 1 , 3 , 6 – 9 ].…”

Section: Introductionmentioning

confidence: 99%

“…Discharge planning plays a crucial role in the post-discharge outpatient coordination since dialysis patients have the added layer of complexity of the dialysis center schedule [ 2 , 4 , 11 , 16 – 18 ]. Furthermore, the lack of a common communication portal between outpatient dialysis centers, hospital discharge teams and outpatient clinics make coordination difficult [ 5 , 17 – 20 ]. In a recent study by Harel et al the number of complicated care transitions was significantly associated with a higher risk of hospital readmissions in a population of Canadian ESRD patients [ 17 ].…”

Section: Introductionmentioning

confidence: 99%

Discharge service as a determinant of 30-day readmission in a cohort of maintenance hemodialysis patients: a retrospective cohort study

et al. 2017

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BackgroundEnd stage renal disease (ESRD) patients on maintenance hemodialysis, are high utilizers of inpatient services. Because of data showing improved outcomes in medical patients admitted to hospitalist-run, non-teaching services, we hypothesized that discharge from a hospitalist-run, non-teaching service is associated with lower risk of 30-day re-hospitalization in a cohort of patients on hemodialysis.MethodsOne thousand and 84 consecutive patients with ESRD on maintenance hemodialysis who were admitted to Montefiore, a tertiary care center, in 2014 were analyzed using the electronic medical records. We evaluated factors associated with 30-day readmission in multivariable regression models. We then tested the association of care by a hospitalist-run, non-teaching service with 30-day readmission in a propensity score matched analysis.ResultsPatients cared for on the hospitalist-run, non-teaching service had lower socio-economic scores (SES) and had longer lengths of stay (LOS), as compared to a standard teaching service, but otherwise the populations were similar. In multivariable testing, severity of illness, (OR 2.40, (95%CI: 1.43–4.03) for highest quartile) number of previous hospitalizations (OR 1.22 (95%CI:1.16–1.28) for each admission), and discharge to a skilled nursing facility (SNF)(OR 1.56 (95%CI:1.01–2.43) were significantly associated with 30-day re-admissions. Care by the non-teaching service was associated with a lower risk of 30-day readmission, even after adjusting for clinical factors and matching based on propensity score (OR 0.65(95%CI:0.46–0.91) and 0.71(95%CI:0.66–0.77) respectively).ConclusionsPatients with ESRD on hemodialysis discharged from a hospitalist-run, non-teaching medicine service had lower odds of readmission as compared to those patients discharged from a standard teaching service.

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Overlooked Care Transitions

Cited by 7 publications

References 8 publications

A Virtual Ward for Home Hemodialysis Patients – A Pilot Trial

A Virtual Ward for Home Hemodialysis Patients – A Pilot Trial

Decreasing hospitalizations in patients on hemodialysis: Time for a paradigm shift

Discharge service as a determinant of 30-day readmission in a cohort of maintenance hemodialysis patients: a retrospective cohort study

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