Right TraC™ Post-Hospitalization Care Transitions Program to Reduce Readmissions for Hemodialysis Patients.

Area of Science:

• Nephrology
• Healthcare Management
• Clinical Interventions

Background:

• Patients undergoing hemodialysis (HD) exhibit high rates of hospitalization.
• This study addresses the need for effective strategies to reduce readmissions in this vulnerable population.

Purpose of the Study:

• To evaluate the impact of a renal-specific intervention bundle, "Right TraC™", on 30-day all-cause readmission rates in hemodialysis patients.
• Secondarily, to assess effects on 90-day readmissions and overall hospital admissions.

Main Methods:

• A nonrandomized trial involving 26 intervention clinics and 18 matched control clinics across West Virginia, Ohio, and Kentucky.
• The "Right TraC™" intervention was implemented in three phases: patient information exchange, post-hospital follow-up, and telephonic case management.
• Readmission rates (per patient-year) were calculated for baseline (2012) and remeasurement (2014) periods, with comparisons made from 2010 to 2015 using repeated measures Poisson regression.

Main Results:

• Thirty-day all-cause readmissions per patient-year decreased in "Right TraC™" clinics from 0.88 to 0.66 (p < 0.001) between 2012 and 2014.
• Overall admissions per patient-year significantly declined in "Right TraC™" clinics (2.51 to 1.97, p < 0.001), with a significant difference in change compared to controls (p = 0.01).
• Readmission rates in "Right TraC™" clinics decreased during the intervention year (2014) but slightly increased after discontinuation in 2015.

Conclusions:

• The "Right TraC™" intervention bundle demonstrated potential in reducing hospital readmission rates among hemodialysis patients.
• The observed reduction in overall admissions suggests a positive impact on patient management and healthcare resource utilization.
• Further research may be warranted to sustain and optimize these interventions for long-term benefits.