DESCRIPTION (provided by applicant): Project summary Transitional care interventions reduce hospital readmissions and slow the progression of declining health in the general population of hospitalized patients. What is not known is the impact transitional care interventions can have for the hospitalized CKD population. CKD patients are in critical need of improved transitional care that includes accurate and comprehensive medication information transfer. The main objective of this application is to pilot-test the effectiveness of a medication
information transfer intervention to improve clinically-relevant outcomes in CKD. To this end, the following Specific Aims will be achieved: 1. Evaluate the impact of transitional care interventions
on acute care utilization following hospital discharge among patients with CKD. 2. Evaluate the impact of transitional care strategies on management of CKD risk factors and complications. Focus groups will first be conducted to assure relevance and to refine the intervention. A qualitative research design with convenience sampling will be used to survey recently hospitalized CKD patients (n~10) and their healthcare professionals (n~10). The medication information transfer intervention will be evaluated in a pilot study using a randomized, single-blind clinical trial design. Participants and the pharmacist interventionist will have knowledge of
group assignment, but the other investigators and research staff will be blinded. Study entry criteria will include hospitalized patients >21 years old (n=120) who have a diagnosis of CKD stages 3-5 (not including those treated by dialysis or kidney transplant). After obtaining IRB-approved written informed consent, patients will be randomized by computer algorithm for group assignment, stratifying according to diabetes status. The pharmacist will visit participants in the
home within 5 days of hospital discharge. The 5As (Assessment, Advice, Agreement, Assistance, and Arrangements) Self-Management Model will be used to implement the medication information transfer intervention. Clinical assessments will be performed at baseline and at 30 and 90 days. Primary outcome measures for Specific Aim 1 will be acute care utilization (emergency department visits and hospitalizations). The main outcomes for Specific Aim 2 will be measures of CKD risk factors and complications. Blood pressure will be the primary outcome for this aim because hypertension control is the most consistent recommendation for slowing CKD progression. Logistic regression analyses will be employed controlling for age, sex, CKD stage, co- morbidities, Charleson score, cognitive status, medication adherence and health literacy. Cost will be analyzed based on charges from hospitalization through the following 90 days using a difference-of- difference approach. This contribution is significant because it will define methods to overcome system barriers that result in impaired quality and continuity of care. The proposed research is innovative because it integrates established clinical strategies with systems approaches to improve patient care, thereby testing a fundamentally new approach to advance CKD management.