Link From Hospital to Home: Ensuring Quality Transitions for CKD Patients

Patients living with chronic kidney disease (CKD) suffer significantly higher readmission rates after discharge than the national all-hospital 30-day rate. Federal-based programs have introduced payment models incentivizing prevention-oriented activities, like transitional care management (TCM) programs, that help patients safely transition from one care facility to their homes. In this quality improvement case study, we assessed our value-based kidney care organization's TCM clinical program, which empowers patients in their post-hospitalization journey by promoting increased awareness of their condition, adherence to medications, and care navigation, ultimately minimizing the likelihood of complications or readmission. CKD patients with moderate to high risk for readmission were included in the analysis. The findings demonstrated that enrollment in the TCM program reduced total hospital readmission rates compared to those who declined enrollment at 7-, 14-, and 30-days postdischarge (P < .01; 7-days, 42% lower; 14-days, 37% lower; 30-days, 25% lower). To reduce patient utilization and increase quality of care after a hospitalization, healthcare organizations should deploy a patient-centered transitional care approach in their care models.