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Kidney Week

Abstract: FR-PO1163

A Nephrology Transition Clinic in the Adult Care Setting: A Pilot Program

Session Information

  • Pediatric Nephrology - I
    October 26, 2018 | Location: Exhibit Hall, San Diego Convention Center
    Abstract Time: 10:00 AM - 12:00 PM

Category: Pediatric Nephrology

  • 1600 Pediatric Nephrology

Authors

  • Nishi, Laura, Northwestern Medicine, Chicago, Illinois, United States
  • Ghossein, Cybele, Northwestern University- Feinberg School of Medicine, Chicago, Illinois, United States
Background

Young adults (YA) with chronic illnesses transitioning care from pediatric to adult medical facilities face many obstacles. Pediatric care providers are mindful of barriers to a smooth transition and the importance of a formal transition process, while adult care providers are often unaware, leading to an inconsistent transition process in the adult care setting. Three years ago, Northwestern Medicine (NM) Nephrology implemented a pilot transition of care program for YA with renal disease transitioning from Lurie Children’s Hospital to NM. We report here on our experiences.

Methods

Pediatric nephrology providers identified patients who they deemed ready to transition to adult providers. Prior to transition clinic, the adult multidisciplinary team, consisting of the nephrologist, physician assistant (PA), and social worker, reviewed patients with the pediatric team. The first appointment occurred at Lurie Children’s Hospital, which is located across the street from NM. Subsequent visits were then held at NM. At the initial visit, the patient was seen by the PA, nephrologist and if deemed appropriate, the social worker. The transition team reviewed each patient bimonthly to determine if proper follow up including testing and appointments had occurred, and if not, the patient was contacted to arrange for these.

Results

A total of 69 patients were seen in a three year period. Of these, 6 patients have been lost to follow up. 5 patients were no longer able to be followed due to insurance changes. 2 patients were deemed not to require further nephrology follow up. 42 patients have followed up as instructed at NM. There are 9 patients who have pending follow ups. 4 patients started peritoneal dialysis and are thus are no longer cared for in the transition clinic. Finally, 1 patient started hemodialysis right away, was subsequently transplanted, and is now seen back in the transition clinic.

Conclusion

Based on our three year pilot experience, transition of care from pediatric to adult nephrology providers can be successfully facilitated with engagement of an adult nephrology team, close communication with a pediatric team, and a formal transition clinic protocol. In the future, we plan to continue this as a formal program in nephrology as well as extending it to other medical specialties within the NM system.