Last March, chief medical officers of 14 major dialysis providers convened a meeting in Chicago. In attendance were the officers themselves, operations personnel and the president of the American Nephrology Nurses Association. We invited NN&I to cover the two-day gathering.

The spirit of the meeting was to share programs and processes that various providers are using to enhance patient outcomes. A condition of attending was a willingness to share information, even protocols, across all providers. There was, indeed, a widespread sharing of those programs that really make a difference in patients’ lives. Everyone agreed to move forward with this open-minded approach; likely, there will be a similar meeting next year to assess progress and advance other programs.

Since last August, NN&I has been publishing a series of reports prepared by the CMOs attending the conference. During the meeting, specific topics were assigned and groups were organized to address subjects such as nutrition, sodium and volume, initiation of dialysis, vascular access, and CKD education. These reports summarize the views of each group on how to improve patient outcomes.

This report, prepared by Peter DeOreo, MD, focusing on how we can improve the transition of care for dialysis patients.

We welcome NN&I readers to offer their own views so we can continue to dialogue on how we can make dialysis care a better treatment. Send comments to

—Tom Parker III, MD • Doug Johnson, MD • Allen Nissenson, MD

Improving the continuity of care

The Department of Health and Human Services has divided the National Quality Strategy into six domains:  1) safety, 2) patient and family engagement, 3) communication and care coordination, 4) preventative health practices, 5) healthy living and, 6) reducing cost through quality improvement.1

Reducing hospitalizations (and re-hospitalizations) will improve the health-related quality of life and reduce the cost of care for dialysis patients.  On average, dialysis patients are hospitalized two times a year, spending an average of 16 days in the hospital.  They have multiple emergency department visits.  They have multiple outpatient procedures.  Each of these episodes of care disrupts their previous steady state. Improving the continuity of care from one treatment environment to another impacts four of the six domains in the National Quality Strategy.

In 2011, 36% of all cause hospitalizations in hemodialysis patients were followed by a re-hospitalization in 30 or fewer days. This rate is twice that for non-ESRD patients.  Hospitalizations account for 38% of the Medicare expenditures for ESRD patients.2 Continuing care from the inpatient setting to outpatient dialysis (and in the opposite direction) is the shared responsibility of the nephrologist, dialysis facility, the hospital emergency department, acute care hospital, and the skilled nursing facility, or nursing home. Incomplete, inconsistent, inaccurate transfer of pertinent clinical data remains a major barrier to a safe handoff of care. This is a time-intensive process that ideally should be electronic—a continuity of care document designed for renal disease-specific issues. Electronic and phone disclosures need to be compliant with HIPAA and HITECH regulations safeguarding protected health information and patient identity.3

(Find more articles on the CMO Intitiative)

Hospitals rightly argue that managing the patient data is a one to many responsibility, as they perceive an obligation to the physician(s), skilled nursing facility, home care agency, dialysis unit, etc., and thus making their reporting complex and extensive.  Currently, hospitals do not have the same obligation to report to the dialysis unit that they have to nursing homes, but should.

There is not yet pervasive use of the community health record through health information exchanges (HIE).  An HIE allows multiple providers to export or contribute information that is aggregated in a patient-centric health record that is then “pushed” back to participants in the exchange.  Until that time, various workarounds allowing handing off variations of paper documents from one provider to the next is necessary.

This article focuses on the core of information that needs to move from an inpatient hospitalization to the dialysis facility by whatever means.  An intelligent process of bringing the patient back into the dialysis facility is a necessary condition for reducing the probability of harm and of readmission.3

There are two immediate goals of this continuity of care document for dialysis patients. First to enable the safe return to the outpatient dialysis setting and second to facilitate continuity of care.  We believe this process should be driven by adherence to a checklist of tasks.  We suggest that the content of such a checklist should include at least the following categories of review.

Safe Return

  • Providers should prohibit the use of “resume previous dialysis orders.”
  • New dialysis orders (weight, dialysate composition, anticoagulation, access)
  • Volume status (have fluid goals been achieved or are they in progress?)

Medicine review

  • New, stopped, adjusted, allergies, conflicts
  • Missing categories (beta blockers, ace inhibitors, etc.)
  • Dosing history of ESAs and Iron
  • Can heparin be used? If not, why not, and for how long
  • Antibiotic course to complete
  • Significant lab (last hemoglobin determination)

(Improving vascular access outcomes in dialysis patients)

Continuity of care

  • Discharge diagnosis
  • Complications
  • Procedures (transfusions, access revisions)
  • Follow up with other physicians
  • Community health referrals (home health, passport, rehab, hospice, etc)
  • Family engagement
  • Advanced directives
  • Implication for IDT
  • Is patient now unstable?
  • Are RD and MSW re-engaged?
  • Was the plan of care revised?

Several renal networks have developed transition care quality improvement activities (QIA).4  Networks 9 & 10, collaborating with Network 4, defined seven change concepts useful in achieving better coordination of care.5

  1. Gain access to hospital electronic health care systems.
  2. Communicate with the nephrologist’s office.
  3. Use a clinical nurse and transition care liaison staff to round on hospital patients and communicate with the dialysis team.
  4. Use a care transition form to communicate between hospital and dialysis facility.
  5. Email/telephone/fax between hospital and dialysis unit.
  6. Obtain discharge summaries.
  7. Include patient and family in communications.

The most important action is to develop the resources in the hospital and the dialysis unit who have responsibility and accountability for this communication and to reduce that relationship to a policy and procedure. Nephrologists should take the lead in this as members of both the hospital staff and the dialysis facility staff.


1. The National Quality Strategy. (last accessed: 11/26/2013.

2. U.S. Renal Data System, USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2013.The reference cited for the above list of change concepts also includes forms for hospital to dialysis unit and dialysis unit to hospital that were used in the care transition QIPs.

4. Care Coordination Endorsement Maintenance 2012: Phases 1 and 2. Technical Report. National Quality Forum. October 2012.

5. A QIO-Renal Network Collaboration:  Addressing Care Coordination (Last Accessed: 11/27/2013)

6. Change Concepts for Improving Care Transitions. ESRD Networks 9 & 10. (Last accessed: 11/27/2013)