Individuals with chronic kidney disease (CKD) and end-stage renal disease (ESRD) tend to have more hospitalizations than those without kidney disease.1 ESRD patients requiring dialysis have particularly high hospitalization rates, and they also have a high risk of being readmitted within 30 days after being discharged.2 Whether the hospitalization was related to the patient’s kidney disease or one of their associated comorbidities, it is often possible to prevent unnecessary readmissions through proactive health management.
Reducing preventable hospital readmissions for CKD and ESRD patients is an important aspect of Healthmap Solutions’ Kidney Population Health Management program. Regardless of the reason the patient was originally admitted, it is important for patients and their providers to work together on an effective post-discharge plan.
How can kidney patients and their care partners play their part in avoiding unnecessary readmissions? In the following guide, we offer helpful tips for patients after discharge to help ensure a smooth, successful recovery and avoid a hospital readmission in the near future.
Before Leaving the Hospital: Create an Action Plan with Your Doctors
A well-defined action plan is your roadmap to recovery. This plan should encompass medication management, provider follow-up appointments, and personalized instructions for at-home care. Be sure to contact your discharging provider, outpatient provider, or your primary care provider (PCP) to make sure you understand your action plan. Here’s how to approach it:
Understand Your Condition – CKD is a complex condition. Understanding CKD and related issues will make it easier for you, your family, and other care partners to keep your get-well plan on track. Ask your doctor and hospital discharge planner to describe your condition as well as the reason you were admitted to the hospital in easy-to-understand terms to be sure you know exactly what will be involved in recovery.
Medication Management – Be sure you get a clear, written medication schedule. Each drug should be clearly labeled with its purpose, dosage, and frequency. Once you’ve left the hospital, avoid stopping any prescribed medications on your own. If you have questions about your medications, inquire with your PCP or the doctor in charge of your care first. Don’t hesitate to ask about potential adverse interactions with over-the-counter drugs or dietary supplements to avoid adverse effects.
Follow-up Appointments – Adverse health events are more likely to occur when a patient has not seen their providers regularly. Follow-up appointments provide opportunities for your care team to monitor your progress after you have left the hospital and adjust your get-well plan as needed. Confirm your initial follow-up appointments before leaving the hospital and take steps to make sure you will have transportation and assistance on those dates.
Special Instructions – Your doctor should provide detailed written instructions on aspects of recovery, such as wound care, rehabilitation exercises, or dietary adjustments. Be sure to review these instructions with your doctor or nurse before leaving the hospital. This information is typically found in the discharge instructions provided by the hospital.
Do Tests and Checks at Home
Monitoring your health at home is a proactive way to catch potential issues early. Here's examples of how to effectively conduct self-checks and tests:
Blood Pressure Monitoring – Regular monitoring can help you and your healthcare provider make informed decisions about your medication and lifestyle. Record your blood pressure readings and note any significant changes to discuss with your physician during your follow-up appointments. You can find a user-friendly Blood Pressure Log Sheet on Healthmap’s website.
Blood Sugar Levels – For people with diabetes, maintaining blood sugar levels within your target range is crucial. Familiarize yourself with the signs of both high and low blood sugar and develop an action plan for each scenario with your diabetes care team. Healthmap offers a Blood Glucose Log Sheet to help our members keep track of their blood sugar levels.
Temperature and Wound Checks – Daily inspections of any wounds for signs of infection are crucial. Know the normal stages of wound healing, and be alert to any deviations, such as fever, increased pain, swelling, redness, odor, or drainage.
Weight Monitoring – Especially important for patients with conditions like heart failure or kidney disease, daily weight checks help track fluid balance. Check your weight every morning in the same way. For example, upon waking up and after using the restroom, step on a scale and log your weight. A sudden increase could indicate a need for medication adjustment or dietary changes. If you gain more than 2-3 pounds in a 24-hour period (or 5 pounds in one week), contact your doctor or health care team.
Know When to Call Your PCP or Specialist
Understanding when to seek medical advice is key to preventing complications. Here’s when making that call is crucial:
Recognizing Warning Signs – Familiarize yourself with the symptoms that warrant immediate medical attention. Early intervention can prevent minor issues from becoming major complications.
Medication Reactions – If you experience unanticipated side effects or if your symptoms significantly worsen after starting a new medication, contact your healthcare provider promptly.
Questions and Concerns – It’s natural to have questions or concerns during your recovery. A quick call to your doctor can provide reassurance and clarity, ensuring you stay on the right track. Most practices have a provider on-call 24 hours per day, including the weekends, and on holidays, to answer off-hour questions or healthcare-related concerns. If you are unable to reach your provider and you are dealing with an emergency, you can always dial 911. Members in Healthmap’s program can also reach out to the Care Navigation team for support.
How Healthmap Solutions Supports the Post-discharge Journey
Through our Kidney Population Health Management Program, Healthmap plays an important, ongoing role in the post-discharge journey. We work to achieve a seamless hospital-to-home transition and provide ongoing support for our members. We do so by:
Providing Proactive Care Navigation – Our Care Navigation team works closely with hospital discharge teams to reach out to all hospitalized members within 48 hours of receiving a discharge alert. This ensures that patients receive timely support and guidance.
Reducing Readmissions – By focusing on post-discharge outreach, Healthmap reduces the risk of 30-day readmissions. This includes medication reconciliation, scheduling physician follow-up visits, and educating patients on their admission diagnosis and discharge plan. The team also prioritizes addressing any outstanding concerns, such as ensuring access to necessary medications.
Coordinating the Transition – Healthmap’s Care Navigation team communicates with skilled nursing facilities (SNFs) and other post-acute care facilities to help coordinate the transition back to the home. By conducting regular follow-ups, our dedicated Care Navigators essentially accompany members throughout their recovery program, providing continuing support and ensuring treatment adherence.
Ensuring Comprehensive Care – Healthmap’s team notifies the providers on a member’s care team upon their discharge from the hospital. This coordination ensures that any necessary follow-up appointments or referrals are promptly arranged, supporting a holistic approach to post-discharge care.
Remember, recovery is a process that requires close collaboration between you and your care providers. By taking an active role in the process, keeping lines of communication open with your care team, and using the resources available from the Healthmap team, you can confidently navigate your post-discharge journey and help achieve the best possible outcomes.
References:
1 https://www.ajmc.com/view/predicting-hospitalizations-for-patients-with-chronic-kidney-disease
2 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9437601/
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