Lack of a comprehensive client assessment on admission to identify care needs can result in re-admission, especially when transition plans are not informed by the findings from these assessments (Herndon et al., 2013; Richards & Coast, 2003; Schall et al., 2013; Sevin et al., 2013). At London Health Science Centre, clients diagnosed with renal disease are typically referred to the General Nephrology clinic where they are assessed and followed up by a nephrologist and nursing staff during their early stages of renal disease (stages 1-2). As the renal disease progresses (stage 3), clients are then transitioned to the Chronic Kidney Disease (CKD) clinic where they are assessed and their plan of care is developed, implemented, and evaluated at each clinic visit by a multidisciplinary team consisting of physician, nurse case manager, social work and dietitian. These 20 minute clinic visits did not provide enough time for the allied health team to fully assess a client’s care requirements and establish a comprehensive plan of care as these clients progressed into late renal disease stage. As a result, clients would stay for an unplanned lengthy clinic visit.
To better meet the needs of our clients, who felt overwhelmed during their first clinic visit by the amount of information and the number of team members consulted in a short period of time, the program made creative and innovative changes to the CKD clinic. We created a one- time, stand-alone clinic specifically targeting clients who are transitioning from the General Nephrology clinic to the CKD clinic. These clients visit solely with the allied health team (social worker, dietitian, nurse case manager, pharmacist and physiotherapist).
The PREP (Participation, Resources, Engagement, Planning) clinic:
• Promotes a positive client experience by allowing clients to meet the multidisciplinary providers individually, in a relaxed yet structured environment
• Provides an opportunity for individual assessment and development of a care plan in partnership with the client and family, understanding their learning needs and the client’s ability to self-manage
• Allows the health care team to use a multidisciplinary approach for planning and delivery of care, as well as an opportunity to coordinate and communicate client needs.
The health care team has seen improved client engagement in the follow up CKD clinics, with clients returning with their Renal My Care Binders, journaling their blood pressures and blood sugars as needed and prepared for CKD clinic visit equipped with questions for the team. The CKD clinic has functioned smoother since the implementation of the PREP clinic as transitional needs of the new patients have been met.
The PREP clinic provides a defining transition point from general nephrology to progressive chronic kidney disease which is scheduled bi-monthly with additional clinics added as the need arises.
Gail Barbour, Coordinator