As a dialysis nurse for over 30 years, I have seen firsthand the importance of care coordination for chronic hemodialysis patients. When done effectively, patients are more likely to receive the right care at the right time, which can lead to better outcomes and fewer hospital admissions and readmissions.

Unfortunately, due to staffing shortages across all healthcare segments, care coordination for hemodialysis patients is often lacking. This can lead to patients receiving unnecessary or inappropriate care, which can be costly and disruptive to their lives. For facilities involved in one of the CMS CKCC programs these unnecessary or inappropriate procedures are also costly to the provider and nephrology practice.

Here are some examples of care coordination challenges:

• A patient was discharged to a long-term-care facility that performs dialysis, but care coordination to arrange treatment at the facility was not done. The patient was readmitted to the hospital until outpatient dialysis arrangements were completed.
• A patient was discharged with outpatient dialysis arrangements, but inappropriate transportation to and from treatment. The patient had a leg amputation and would require special transportation due to the inability to walk and self-transfer into a vehicle. The acute care coordinator scheduled an Uber transport which the patient could not use due to medical status. The patient missed outpatient treatment for a week before coming to the hospital by ambulance on a Saturday for emergent dialysis.
• A patient who receives hemodialysis on a Monday-Wednesday-Friday schedule had a peritoneal dialysis (PD) catheter placement on Friday. The patient ended up being admitted to the hospital overnight to receive dialysis since the outpatient hemodialysis appointment was missed. PD catheter placement does not usually necessitate a stay in the hospital, but because the placement was scheduled on the patient’s normal treatment day that is what happened. Non-emergent procedures should not be scheduled on regular treatment days to avoid this situation.
• A Nephrology Nurse practitioner related that during her hospital rotation, the Infectious Disease team had been ordering central line placements for chronic hemodialysis patients who were being discharged and supposed to receive antibiotics at outpatient treatment. Since chronic patients already have AV access these procedures are not necessary. She was able to stop placements on several patients, but one patient slipped by and had the procedure done. The patient was understandably angry upon learning what happened. 

What can we do to improve care coordination for hemodialysis patients?

Here are a few suggestions:

• Care coordination plans should be developed for all hemodialysis patients who are admitted to the hospital. These plans should include clear arrangements for transportation to and from outpatient dialysis appointments, as well as plans for any other medical care that the patient may need after discharge.
• Communication between acute care providers and outpatient dialysis providers needs to be improved. This will help to ensure that patients are receiving the right care at the right time, regardless of where they are being treated.
• Non-emergent procedures should not be scheduled on regular dialysis treatment days.

By working together, we can improve care coordination for hemodialysis patients and help them to live healthier and more fulfilling lives.

Use this checklist that we have created to guide this practice in your own clinic.