This is an evaluation of a program developed by a team of nephrologists, operations experts and researchers. The goal is to provide CKD patients with a better way to transition to life on dialysis - one that emphasizes even more individual clinical, psychosocial and lifestyle needs. On top of high-quality clinical care, the 4-week Optimal Transition program supports patients as they adjust to treatment and learn to live the best life possible. This is done through a robust education curriculum and a trust-building approach.
In this program evaluation the investigators will be reporting on the following program outcomes: 1. Clinical and psychosocial stabilization: to include lab values, clinical dialysis parameters, patient-reported symptoms, quality of life, hospitalization and mortality rates. 2. Dialysis modality choice with satisfaction with the modality education and continued modality use over 24 months. 3. Patient knowledge, activation, and satisfaction. 4. Program parameters such as time, costs, referral rate, admissions and length of stay within the program.
Study Type
OBSERVATIONAL
Enrollment
20
Evaluation of the following: * Laboratory values at admission, week 4, and day 90. * Pre and post blood pressure at week one and week 4. * Intradialytic hypotension at week one and week 4. * Ultrafiltration rates at week one, week 4, day 90, day 180, and day 360. * Target weight defined and achievement in week one and week 4 and changes between week one and week 4. * Dialysis access type at week one and day 90. * Hospitalization and mortality rates.
Surveys will assess participants' Symptom index, Quality of Life, Patient Activation as well as satisfaction with the program.
Satellite Healthcare Oakland
Oakland, California, United States
RECRUITINGSatellite Healthcare Sacramento
Sacramento, California, United States
RECRUITINGSatellite Healthcare Chickasaw Gardens
Memphis, Tennessee, United States
RECRUITINGEvaluation of clinical stabilization through standard clinical dialysis labs
Evaluation of changes in the Standard of care monthly dialysis labs
Time frame: On admission, week 4 and day 90
Evaluation of clinical stabilization through standard clinical dialysis blood pressure measurements
Evaluation of any changes in the Pre and post dialysis blood pressures for each patient which are collected as part of the patient's dialysis flow sheet.
Time frame: At week one and week 4.
Evaluation of clinical stabilization through standard clinical dialysis measurements of Intradialytic blood pressures
Evaluation of any changes in the incidence of Intradialytic hypotension as assessed by review of the patient's dialysis flow sheet.
Time frame: At week one and week 4.
Evaluation of clinical stabilization through standard clinical dialysis measurements of ultrafiltration
Evaluation of interval changes in the patient's ultrafiltration rates as measured by the dialysis machine and reported on the patient's dialysis flow sheets.
Time frame: At week one, week 4, day 90, day 180 and day 360.
Evaluation of clinical stabilization through standard clinical dialysis measurements of weight
Target weight defined and achieved as measured by standard of care at the unit
Time frame: At week one and week 4, and changes between week one and week 4.
Evaluation of clinical stabilization through standard clinical dialysis measurements
Dialysis access type as reported in the dialysis treatment sheets
Time frame: At week one and day 90
Evaluation of clinical stabilization through standard clinical dialysis collection of patient hospitalizations.
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Data will be collected using tracking tools throughout the program.
Hospitalization rates as reported in the standard dialysis record for all patients
Time frame: Day 30, day 90, 6 months and 12 months
Evaluation of clinical stabilization through standard clinical dialysis records.
Mortality rates as reported in the standard dialysis record for all patients
Time frame: Day 30, day 90, 6 months and 12 months
Evaluation of clinical and psychological stabilization through a quality of life measurement.
The EQ-5D tool will be used
Time frame: Week 4
Evaluation of clinical and psychological stabilization through assessment of patient symptoms.
The ESAS-r:Renal tool will be used
Time frame: Week 1 and Week 4
Satisfaction with the modality options education
Survey of patient experience
Time frame: Week 1 and Week 4
Type of Dialysis Modality chosen by the patient
Dialysis modality choice as reported by the patient
Time frame: Week 1 and Week 4
Actual Type of Dialysis Modality used by the patient
Dialysis modality as reported on the standard dialysis treatment sheets
Time frame: week 4, month 3, 6, 12, 18 and 24
Evaluation of patient knowledge of dialysis and modalities
Weekly focused one on one discussion where the patient is questioned about his/her understanding of dialysis, his/her progress, questions, concerns using a questionnaire developed by the investigator
Time frame: Week 1, 2, 3, 4
Evaluation of patient activation
Survey measuring patient activation (PAM-13) survey
Time frame: Week 3 and month 3
Evaluation of patient satisfaction
Survey of satisfaction with the program
Time frame: Week 4 or discharge from the program whichever comes first
Evaluation of the program process for time utilization
Time per patient for visits from program start to completion for each patient
Time frame: Week 1 through week 4
Evaluation of the program process for cost utilization
Time, and thus cost, for personnel to complete the program with each patient from entrance to completion or early termination.
Time frame: Week 1 through week 4
Evaluation of the feasibility of the program
Number of referrals to the program and subsequent number of admissions to the program.
Time frame: Week 1 through week 4
Evaluation of the program efficiency
Average length of stay for each patient in the program.
Time frame: Week 1 through week 4