ArticleJournal of patient experience2025
Link From Hospital to Home: Ensuring Quality Transitions for CKD Patients.
Article in Journal of patient experience, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
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Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Authors and funding
7 authors.
Funding
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Abstract
Patients living with chronic kidney disease (CKD) suffer significantly higher readmission rates after discharge than the national all-hospital 30-day rate. Federal-based programs have introduced payment models incentivizing prevention-oriented activities, like transitional care management (TCM) programs, that help patients safely transition from one care facility to their homes. In this quality improvement case study, we assessed our value-based kidney care organization's TCM clinical program, which empowers patients in their post-hospitalization journey by promoting increased awareness of their condition, adherence to medications, and care navigation, ultimately minimizing the likelihood of complications or readmission. CKD patients with moderate to high risk for readmission were included in the analysis. The findings demonstrated that enrollment in the TCM program reduced total hospital readmission rates compared to those who declined enrollment at 7-, 14-, and 30-days postdischarge (
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