A Virtual Post-Discharge Intervention For Patients With CKD

A Virtual Post-Discharge Intervention to Prevent Hospital Re-Admissions in Patients With CKD

This pilot, interventional study is testing a combination of remote, virtual interventions, delivered to patients at home to patients with chronic kidney disease (CKD), with the goal of reducing admissions to hospital.

Chronic kidney disease and kidney failure increase the risk of hospitalizations. Many hospital admissions are potentially avoidable. This pilot, interventional study is testing a combination of remote, virtual interventions, delivered to patients at home, with the goal of reducing admissions to hospital. The hypothesis for this pilot work is that the proposed interventions will be adopted by patients and will improve mental health, physical function, quality of life, and disease self-management, which are all key potential mediators of hospital readmission risk in patients with chronic kidney disease.

Inclusion Criteria:

• Adults with CKD (defined as an estimated glomerular filtration rate <30mL/min/1.73m2, including hemodialysis)
• Able to provide informed consent.
• Ongoing follow-up by the St Joseph's Hospital Hamilton Kidney Care Clinic or Dialysis Program and with a recent hospital admission.

Exclusion Criteria:

• Unable to speak or understand English.
• Significant cognitive impairment (as per the treating inpatient care team)
• Serious mental illness (schizophrenia, severe untreated bipolar disorder, psychosis, active suicidal ideation)
• Significant vision or hearing impairment that prevents use of the technology or participation in any of the intervention components.
• Being discharged to long-term care, rehab or complex care.
• Peritoneal dialysis
• Home hemodialysis
• Functioning kidney transplant