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Facilitating the achievement of optimal wellness for renal disease patients

 

Care Transitions

fistula illustration

Safely and effectively sending patients to the hospital and receiving patients from the hospital are fundamental to improving transitional care. Obtaining patient information from hospitals in a timely manner after patients are discharged and return to outpatient dialysis has always been a major area of concern. An effective communication process is essential to ensure safe patient hand-offs between all healthcare facilities whether it is between dialysis facilities, hospitals, nursing homes, or ambulatory care centers and should require the active participation of both a sending provider and a receiving provider.hospital illustration

Establishing a good system of communication between healthcare settings is the key to good care transitions. The Change Concepts listed below were developed by The Renal Network, Inc. by collecting information from a small number of dialysis facilities in the Network 9/10 area.   Every facility has different circumstances, faces different barriers and will have different processes. No process is right or wrong and may change over time. The Network has attempted to rank the most effective and efficient processes below as well as provide some resource material.

You can also use this Care Transitions Toolkit


1. Gain access to hospital electronic healthcare systems or Health Information Exchange Systems.

    Contact appropriate hospital personnel for permission to obtain access to their computer system. Designate dialysis staff to monitor hospitalization information on facility patients. The majority of necessary information can be obtained by the designated staff member. Missing information such as medications may need to be obtained by other means. Access agreements are HIPAA compliant. Download sample confidentiality agreement. [PDF, 128Kb]
1a. Contact state Health Information Exchange organization. 

Health Information Exchange (HIE) is the mobilization of health care information shared electronically between health providers who are giving care to an individual. People often visit different health care offices, physicians, and other providers when getting help with a medical condition. With an HIE, a patient’s information is accessible wherever the patient seeks medical care.

For more information on the development of HIE in the Network 9/10 area, go to the respective websites listed below.

    Illinoishtttp://www2. ILHIE.Illinois.gov

      ◊  Metropolitan Chicago Health Information Exchange is the mobilization of health care information shared electronically across organizations within a region or community between health providers who are giving care to an individual. People often visit different health care offices, physicians, and other providers when getting help with a medical condition. With an HIE, a patient's information is accessible wherever the patient seeks medical care. http://www.mchc.org

2. Communicate with the Nephrologists office

    Establish a relationship with the nephrology office staff. The nephrologist may have been sent patient hospitalization records that could be copied for the dialysis facility. The office also may have access to the hospital computer system or may have a better opportunity to gain access. The office staff could then share hospitalization information with dialysis staff.

3. Utilize a clinical nurse, nurse practitioner etc (care transition liaison staff)

    Designate a person(s) to be responsible for communicating information to appropriate personnel. Read an abstract [PDF, 29Kb] of the article on North Carolina nursing model. An excerpt [PDF, 100Kb] of this article is available from HighBeam. Neyhart, C.D., McCoy, L., Rodegast, B., Gilet, C.A., Roberts, C., & Downes, K. (2010). A new nursing model for the care of patients with chronic kidney disease: The UNC Kidney Center Nephrology Nursing Initiative. Nephrology Nursing Journal, 37(2), 121-131.

4. Utilize a care transitions form to communicate information between the hospital and dialysis facility.

5. Email /telephone/fax information between hospital staff and dialysis.

    Establishing regular communication with hospital staff will improve information exchange. Consider holding a conference call with appropriate staff to discuss patient.

6. Obtain discharge summaries and other hospital records from medical record departments.

    Discharge summaries may be missing vital information. Missing information may need to be obtained or clarified by other means.

7. Include the patient/and or family members in your communications!!!

    The patient and/or family may be able to provide details on their hospitalization. Regular communication with the patient or family/ caregiver may provide valuable information about the patient’s condition and keep the dialysis staff informed of their condition.