Reducing Hospitalizations, Readmissions and ER Visits

There are numerous reasons a dialysis patient may not be able to achieve and maintain optimal health. Health deficits may be related to health conditions, such as but not limited to, anemia, diabetes, cardiovascular disease, or diagnosed and undiagnosed mental health issues. 

Health deficits may be related to patient behavior, such as but not limited to, not taking medication as prescribed, failure to attend check-ups, eating an unhealthy diet, smoking tobacco, using recreational drugs, excessive alcohol use, lack of exercise, or missing or shortening dialysis treatment. Health issues may be related to an unstable social support system and/or financial problems, such as but not limited to, access to food, shelter, transportation, clothing, medication, medical care, and/or emotional support, making patients potentially unable to care for themselves.

We work with facilities to incorporate a focus on the reasons for health deficits to mitigate hospital admissions, hospital 30-day readmission, and outpatient emergency department visits.

2022-2026 NATIONAL GOALS:

• Achieve a 20% decrease in hospital admissions for the Primary Diagnosis Categories*

• Achieve a 20% decrease in hospital 30-day unplanned readmissions for the Primary Diagnosis Categories* following an admission for a diagnosis from the Primary Diagnosis Categories

• Achieve a 20% decrease in outpatient emergency department visits for the Primary Diagnosis Categories*

*Priority Diagnosis Categories

Facility Resources

• ESRD NCC Hospitalizations Change Package - Key Change Ideas for Dialysis Facilities to Drive Local Action

• Discharge Checklist for the Dialysis Patient

• QAPI Toolkit

• Transitions of Care Post- Hospitalization Checklist

• Monthly Chairside IDT Meetings- ESRD Forum Approved Best Practice

• Medication Conversion Guide

• Zone Tool: Post Dialysis (English / Spanish)

Patient Resources

• 4 Ways to Empower Yourself to Cope with COVID-19

• 10 Reasons to Get a PCP (English / Spanish)

• Be Heard: Tips for Talking with Your Care Team (English / Spanish)

• Consider This Before Heading to the ER (Flyer)

• COVID-19 Self-Management Zone Tool (English / Spanish)

• Crunching Numbers: Missing Dialysis Treatments Adds Up (English / Spanish)

• Diabetes:

  • Learning About Diabetes – fact sheets available in English or Spanish

  • Take Care of Your Feet for a Lifetime – A booklet for people with diabetes

  • HYPERglycemia: Know the Symptoms

  • HYPOglycemia: Know the Symptoms

  • Healthy Feet Matter

• Fluid Management and Control for Kidney Disease Patients on Dialysis (Video)

• Guide to a Healthier You

• High Blood Pressure: 

  • Sodium 101: Put Your Sodium Smarts to the Test

  • Blood Pressure 101: Know the Basics

  • Do You Know How to Measure Your Blood Pressure?

  • CDC’s Managing My Blood Pressure

  • CDC’s Blood Pressure Log

  • Video: Tips for Taking Blood Pressure Medicines as Described

  • Video: Taking Control of My Blood Pressure: D'Angelo's Story

  • Video (Spanish): Vital Signs de los CDC: Control de la presión arterial

  • Video (Spanish): Consejos para tomar los medicamentos para la presión arterial según las indicaciones

• Kidney Patient Care: Your Guide to Using Telemedicine

• Obesity and Nutrition: 

  • Kidney Cookbook: A Family Recipe Book for Kidney Patients

  • On the Go: Kidney Friendly Fast Food – includes pictures of suggested fast food options, frozen meal options, snacks, lunch ideas, etc.  

  • My Physical Activity Diary

  • My Food Diary

  • National Heart, Lung, and Blood Institute’s: Portion Distortion: Do You Know How Food Portions Have Changed in 20 Years?

• We Need to Know (English / Spanish)

• Your Fluid Intake Matters! (English / Spanish)

Improving Transitions of Care

• Transitions of Care Toolkit

Network 3 Contact 

Annabelle Perez
Phone (609) 490-0310 ext. 2424
aperez@qualityinsights.org