“One of our core values in the Division of Nephrology is to improve the health of our patients,” says Benjamin Humphreys, MD, PhD, Joseph P. Friedman Associate Professor and Chief of the Division of Nephrology.
The Division of Nephrology has been awarded a two-year grant from the Barnes Jewish Hospital (BJH) Foundation for a proposal to reduce 30-day hospital readmissions for ESRD patients.
On average, a dialysis patient is admitted to the hospital twice a year and over 30% of those admissions will have an unplanned recurrent hospitalization within 30 days. This is double the readmission rate of non-dialysis Medicare beneficiaries.
Frequent hospital readmissions contribute to high mortality rates and poor health-related quality of life of ESRD patients, and are costly, as well, to the dialysis unit and hospital involved. Improving readmission rates is beneficial to all involved.
The two in-center dialysis centers operated by Washington University – Chromalloy American Kidney Center and Forest Park Kidney Center – manage approximately 400 patients, as well as another 200 patients in the community. In 2016, of the 771 hospital admissions for these patients there was a 28% rate of readmission within 30 days.
Humphreys states that improving the readmission rates “will require direct monitoring, enhanced communications between providers and patients, specific and focused patient education, and interactive provider interventions”. The plan is to establish a robust transitional care program to target dialysis patients admitted to Barnes Jewish Hospital for intensive follow-up to prevent readmission.
Humphreys notes, “I am excited that this grant from the BJH Foundation will allow us to test new ways of keeping our dialysis patients out of the hospital, and in so doing, reduce costs, improve outcomes and enhance patient quality of life.”
Specific aims of the program are:
- Create a 30-day readmission risk-assessment tool that will allow optimal communication between the provider and the patients. Patients will be categorized as a low, medium, or high readmission risk based on criteria such as the patient’s social support system, laboratory parameters, adherence record, discharge destination, and dialysis modality.
- Once the readmission risk is assigned, an intervention plan will be developed to meet the challenges of each patient’s individual needs when discharged. The plan will focus on matters such as reviewing medication and discharge instructions with both the patient and caregiver, providing dietary support and counseling, scheduling visits by nurse coordinator/physician during first week post discharge, following-up with phone calls to the patient/caretakers, and ensuring appointments are kept with non-renal outpatient providers.
- Develop patient education tools to target clinical problems that affect readmission rates. This will include development of patient-friendly tool to manage medication, diet, and fluid restriction at home and one-on-one education with patients and families.
- Monitor and track patient outcomes.