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논문분류	춘계학술대회 초록집
제목	Transitional Care for Chronic Kidney Disease with Fluid Overload: from Hospital to Home
저자	Zhihua Huang
출판정보	2024; 2024(1):
키워드
초록	Objectives: Fluid overload in kidney disease is associated with frequent hospitalizations and mortality. The Hospital-to-Home (H2H) program is a home-based transitional care program that aims to follow up on patients’ medical conditions, institute timely interventions in the early recurrence of fluid overload, improve patient self-management through education, and address psychosocial factors that can lead to hospital readmissions. We evaluated the adoption of the H2H program for patients with kidney disease and fluid overload. Methods: Single-center implementation study of H2H for fluid overload in non-dialysis chronic kidney disease during its pilot. Nephrologists referred eligible patients with fluid overload during hospitalization or nephrology consults. Following the RE-AIM framework1, we evaluated adoption based on referral success rates and acceptance among nephrologists using the self-administered, anonymized Normalization of Complex Interventions – Measure Development (NoMAD) survey three months after the pilot. Results: Among 18 referrals, 12 patients were successfully enrolled into the program (66.7%); four were enrolled into other community-based programs, one patient's caregiver refused participation and one patient was eventually referred for institutional care. The NoMAD survey was completed by 12 nephrologists with a median age of 36.5 (32.5, 40.5) years; 75% had worked with patients for more than 10 years while 25% had worked at the current healthcare institution for more than 10 years. Table 1 showed that while most valued and supported the program, they found the program unfamiliar and 42% were not aware of the effects of the program; some also had concerns about integrating H2H into their existing work (33%) and confidence in other people’s ability to use the program (42%). Conclusions: Identifying barriers to adoption can allow targeted implementation strategies such as reminding clinicians, facilitating referrals, and providing feedback on appropriate referrals and clinical outcomes of patients enrolled in the program.
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