EXTEND DIALYSIS CENTER SUPPORT INTO THE HOME
Aging patients with end stage renal disease who are relatively fit require less ER visits and hospital care than those that are frail. They require overall less healthcare services in general. There are specific evidence-based strategies that can be deployed to prevent frailty and dementia in high risk patients with end stage renal disease. Due to a provider shortage and to limited training in exercise, food and social support as medicine, these strategies are currently not deployed within end stage renal disease care.
Primary care teams and medical specialists do not currently have the capacity to measure, monitor or treat the major primary determinants for frailty, dementia and for healthcare utilization in general. 80% of these determinants require the self-management of:
Pre-frail and frail patients at risk for falls, dementia and hospitalization with end stage renal disease can now receive a referral for telehealth support from a prevention team of physiatrists and pharmacists at home. This telehealth support is facilitated by a prevention navigator who visits the patient wherever they reside.
Patients receive a rehabilitation medicine consult that identifies any barriers that are effecting fitness and functional capacity like pain. The physiatrist then prescribes a self-management care plan and pharmacist support for:
In addition, patients receive specialized telehealth tablets for home that enable the physiatry-pharmacy teams to deliver frailty prevention utilizing best practices from proven models that include cardiac rehabilitation, pulmonary rehabilitation and the Lancet commission for dementia prevention.
