EMPOWERED – A Renal Care Pathway for Chronic Kidney Disease Patients as Partners

Introduction In October 2011, based on patients/carers and staff interviews plus research of clinical guidelines, the development of the Renal Care Pathway facilitated a new model of case management, embedded into clinical practice, empowering pre-dialysis patients to self-manage their condition.

Aim To develop and implement an individualised Renal Care Pathway for all pre-dialysis patients by empowering patients to self manage, thus improving the uptake of home dialysis therapies.

Method • stakeholder Engagement identified the

development of a renal care plan as the ideal solution to streamline renal care for pre-dialysis patients

• working party developed pathway frame work and documentation

• identified best practice via liaison with Chronic/Complex Care Program

• adapted appropriate model to suit renal patients’ needs

• education of staff regarding changes to care planning

• development of an implementation strategy

Results • 100% (n=179) of new pre-dialysis patients

commenced a structured multi-disciplinary care pathway between May 2012 and April 2013

• number of patients planned for home dialysis rose from 19% to 69% (n=101), (Graph 1)

• increased uptake in home dialysis (45%) empowering patients to make decisions about treatment choice

• overall improvement in care coordination and patient satisfaction (Graph 2)

Conclusion It is evident that a Renal Care Pathway embedded into Clinical Practice improves care co-ordination, enhances patient preparation for dialysis, improves patient psychosocial welfare, increases number of patients commencing home dialysis and empowers patients giving them the confidence, knowledge and skills to be actively engaged in their own care.

Acknowledgements Authors:

Associate Professor Josephine Chow, Manager, Clinical & Business Service, SWSLHD

Kim Jobburn, Business Support Officer, Clinical & Business Service, SWSLHD

Professor Michael Suranyi, Director, SWSLHD Renal Services,

The authors would like to acknowledge all the staff from SWSLHD Renal Service

Graph 2 - Patient Centre Dimensions of Care Issues

Graph 1 –Planned /Commenced Home Dialysis May 12-Apr 13

0%

2%

0% 1%

69%

28%

Graph 1- Planned/ Commenced Home Dialysis May 2012-April 2013

Total number of patients commenced Facility HD but planned for home dialysis (0%)

Total number of patients on conservative but planned for home dialysis (2%)

Total number of deceased (0%)

Total number of patient planned for home dilaysis but had pre-emptive transplant (1%)

Total number of patients planned for home dialysis NOT commenced dialysis (69%)

Total number commenced on home dialysis (28%)

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Information & Education Patients

Access to care Co-ordination & Integration

of Care

Emotional Support

Transition & Continuity of

Care

Issue

Frequncy

Dimensions of Care

PT - CENTRED DIMENSIONS OF CARE ISSUES:PRE VS POST IMPLEMENTATION OF CARE PLAN

Pre-Implementation

Post Implementation