Virtual Ward for Home Dialysis
Virtual Ward for Home Dialysis
Home based renal replacement therapy (RRT), including peritoneal dialysis (PD) and home
 hemodialysis(HHD), offers enhanced quality of life and clinical advantages compared to
 conventional in-center hemodialysis. Patients with end stage renal disease, that is failure
 of the kidneys such that dialysis is required, are at high risk for adverse health events
 especially during a period of transition following a change in care settings. The
 investigators aim to implement a Home Dialysis Virtual Ward (HDVW) strategy of telephone
 follow-up, which is targeted to minimize gaps of care during transitions in care.

 The investigators aim to have clinicians follow patients by telephone if they meet one of the
 following four criteria;

 1. Discharge from hospital.

 2. Having an interventional procedure.

 3. Prescription of an antibiotic.

 4. Completion of Home Dialysis training.

 The major goal of this HDVW initiative is to provide appropriate and effective supports to
 medically complex patients in a targeted window of vulnerability.
End stage renal disease (ESRD) is kidney disease that requires dialysis or kidney transplant
 to replace lost kidney function. The most common renal replacement therapy in North America
 is conventional, in-center hemodialysis (CHD). Home dialysis - including peritoneal dialysis
 (PD) and home hemodialysis(HHD)offers benefits to quality of life, patient satisfaction and
 clinical advantages, including better survival compared to CHD. (references 1-11 in the
 protocol).

 Patients with (ESRD) have a high burden of co-morbidity. Periods of transition of care from
 acute care to other settings are thought to represent times of increased vulnerability. Since
 patients who require home dialysis have high co-morbidity and have complex medical care
 issues, the investigators seek to improve transitions of care for these patients with a novel
 strategy of follow-up.

 When patients have been hospitalized, had treatment for an infection, had a procedure, or
 have just transitioned to home dialysis therapy,the investigators aim to decrease gaps in
 care by having a clinician follow-up by telephone with these patients in a scheduled way.

 During the telephone call the clinician will assess the patients care and symptoms, and make
 adjustments to prescriptions of medications and dialysis, or referrals to additional care as
 required. Evaluation of care will include:

 1. Indication for admission to the Virtual Ward.

 2. Dialysis prescription.

 3. Demographic and comorbidity data.

 4. Medication reconciliation.

 5. Symptom Assessment.

 6. Dietary review.

 Symptoms will be evaluated using a standardized patient assessment tool,the Charlson
 Comorbidity Index and the modified Edmonton Symptom Assessment Scale.

 At the end of the Virtual Ward follow-up period, patients will be asked to complete a Patient
 Satisfaction Questionnaire.

 Data from a preliminary vanguard pilot phase of 84 assessments done in 21 patients over 2
 months indicates that 170 to 200 patients recruited from eight sites during a 10 month period
 should be sufficient to allow analysis of the data collected.

 Each of the participating Investigator's will have input into the study conduct and
 publication preparation.
Inclusion Criteria:

 -  Patient in the home dialysis program (PD and HHD)and on of the following:

 -  Discharge from hospital following an inpatient admissions

 -  Medical procedure (e.g. vascular access procedure).

 -  Treatment with antibiotics.

 -  Completion of home dialysis training program.

 Exclusion Criteria:

 -  Decline consent.

 -  Unable to participate - (e.g. no phone at home, language barrier)