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Four Best Practices for Kidney Transplant Care Coordination

When patients with end stage renal disease (ESRD) are eligible for and interested in kidney transplantation, dialysis clinics can employ industry best practices to more effectively coordinate care with the transplant center while focusing on the patients’ needs and preferences. Incorporating the following four actions along patients’ paths to transplant may help facilitate a more efficient workflow from dialysis clinic to transplant center (and vice versa), and is important for achieving the best-possible patient experience and most-favorable clinical outcomes.

  1. Incorporate transplant referrals into the standard care protocol. The first and most basic best practice is for the dialysis care team to incorporate a transplant referral into the standard care protocol for each of their ESRD patients. The dialysis clinic can help ensure that patients interested in exploring a kidney transplant have the opportunity to visit a transplant center for the referral. Whenever possible, the dialysis care team can also provide patients and the transplant center a capsulized summary of the patients’ medical history including their history on dialysis. This helps the transplant center to understand the patients’ health status, verify information with each patient and hopefully expedite the process of testing and evaluation. At the same time, it provides patients the opportunity to correct any misinformation and to become more engaged with their transplant process.
  2. Identify a point person to coordinate transplant evaluations and preparation. For the transplant evaluation process, a point person at the dialysis clinic or transplant center should be identified to ensure the evaluation work-up is completed in a timely manner. While this is often a specific coordinator at the transplant center, having a point person at the dialysis clinic as well can help the patient know whom to go to with questions at either location. Because pre-transplant patients must undergo a battery of tests in a short timeframe (typically two to three months), care coordination is critical. It is also imperative for the dialysis clinic and transplant center to communicate test results in a timely manner, as the results offer valuable health information, including health conditions that might require immediate attention.
  3. Facilitate ongoing communication during the waitlist period. Once patients have been evaluated and added to the kidney transplant waitlist, the dialysis care team should share with the transplant team any clinical issues and pertinent data related to waitlisted patients on a regular basis. Waitlisted patients should be included in these communications, as well, so they are aware of the ongoing conversations and, ultimately, anything that could affect their transplant status. The transplant center should provide a statement regarding transplant reevaluation timing for patients on the waitlist (to address any health status changes that may affect waitlist status). If this is not provided, or does not clearly indicate timeframe information, this should be requested.
  4. Establish protocols for addressing transplant failure. Despite the frequent success of transplantation, there are unfortunately, many kidney transplant recipients who face failure of their transplant each year due to a variety of factors. Dialysis teams should have protocols in place for resuming dialysis care for those patients who experience kidney transplant failure, —following best practices for incoming dialysis patients, including dialysis modality education, access placement and training. Care teams should be aware of the unique challenges faced by these patients. It is not unusual for patients facing transplant failure to feel disappointed, hopeless, and a loss of self-worth—which for some patients, can culminate into clinical depression. Even when facing transplant failure, patients may need to remain on transplant medications to maintain any residual kidney function and reduce potential complications from the transplant. Care teams should work with patients to address psychosocial issues and medication adherence as needed.

The common thread among these care coordination best practices is communication. Effective communication (that includes logistics and meaningful information) helps the dialysis care team and the transplant center provide patient-centered care, increase patient awareness and engagement, and ultimately achieve more-favorable outcomes.

Bryan Becker, MD, MMM, FACP, CPE

Bryan Becker, MD, MMM, FACP, CPE

Bryan N. Becker, MD, is chief medical officer of DaVita Integrated Care and has nearly 20 years of physician executive experience. He received his AB in English at Dartmouth College and MD from the University of Kansas, and, after training at Duke and Vanderbilt, he led the nephrology group at the University of Wisconsin and developed a new kidney care venture called Wisconsin Dialysis, Inc. He also served as CEO at the University of Illinois Hospital and Clinics and president of the National Kidney Foundation. Before joining DaVita Kidney Care, Dr. Becker served as President of the University of Chicago Medicine (UCM) Care Network, a more than 1,000 physician clinical integration organization, and Vice President, Clinical Integration and Associate Dean, Clinical Affairs at UCM. Twitter: @bnbeckermd