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Hand in hand--transitional care.

Transitioning is a very important part of all patients' care. Transitioning is especially important for patients in our Kidney Care Centre (KCC) or pre-dialysis clinic, as most have Stage 4 or 5 chronic kidney disease. They will eventually need to transition to dialysis, renal transplantation or, for those patients choosing conservative approach, to palliative care. These patients can have feelings associated with anxiety, denial, and frustration, and can have great difficulty in trying to make decisions.

To help patients with this transition, we have a multidisciplinary team approach consisting of the nurse, nephrologist, pharmacist, dietitian, social worker, diabetes nurse educator, transplant nurse coordinator, and the nurse navigator. The nurse navigator provides information and support to patients and their families in order to help them understand their choices and to assist them in making the right decision, one that will best fit their lifestyle and be less disruptive to their everyday life.

In order to provide seamless transition, effective communication is very important. We provide verbal, as well as written patient information when transferring the care to hemodialysis and home dialysis nursing staff. We have meetings to review our KCC patients with our transplant coordinator for those patients being considered for live donor renal transplant. We frequently review our patients to ensure they have chosen their renal replacement therapy (RRT). In addition, we review their dialysis access status with our body access coordinators. For those who have chosen conservative care, we continue to provide support and our social worker has an important role in connecting them with palliative care, as needed.

There are still more opportunities to improve the transition of care within our program such as providing follow-up and further emotional support to patients and their families, and connecting with primary care providers. We will continue to work towards providing transitional care that is seamless and most beneficial to our patients.

Hong Gao BScN, RN, CNeph(C), Toronto, ON, Tara Robertson, RN, Toronto, ON, Mina Kashani, RN, CNeph(C), Toronto, ON

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Author:Gao, Hong; Robertson, Tara; Kashani, Mina
Publication:CANNT Journal
Geographic Code:1CANA
Date:Apr 1, 2017
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