The US Centers for Medicare & Medicaid Services' (CMS) Center for Innovation has awarded a $2.5 million grant that will enable the North Shore-LIJ Health System to expand its “Healthy Transitions” program for people with chronic kidney disease.
The Healthy Transitions program, led by the North Shore-LIJ’s Janet and John Raggio Nephrology Institute, brings together various parts of chronic kidney disease patient care. The program involves registered nurses (RNs) visiting patients with chronic kidney disease at their home to explain and evaluate the patients’ medications, food and living situation. After the initial visit, the RNs make home visits as needed and call the patients at least once a month. In addition to the nursing component, the Healthy Transitions program allows for better communication and less care fragmentation between patients’ various physicians. It uses an informatics system to help avoid medication discrepancies and drastic changes in care that may be detrimental to the patient. The Healthy Transitions program also allows for in-home dialysis; nutrition evaluation and counseling; and depression monitoring, among other things. The nurses will coordinate with the nephrologists and a daily report about the patient’s care and goals will be created.
“This program is part of the new model of care that is being created to treat the booming population of older people with chronic diseases,” said Steven Fishbane, MD, vice president for network dialysis services for the North Shore-LIJ Health System. “We have gotten such a positive response to the program and great outcomes in the first year and a half of this program, we are looking to expand it and help more patients.”
About 270 chronic kidney disease patients are currently enrolled in North Shore-LIJ’s Healthy Transitions Program, which has been in place for about two years. With the $2.5 million grant, Dr. Fishbane estimates the program can be expanded to an additional 400 patients.
The Healthy Transitions program was one of 12 in the country that was selected by CMS to receive this distinction.