A Person-Centered Interdisciplinary Plan-of-Care Program for Dialysis: Implementation and Preliminary Testing.

Area of Science:

• Nephrology
• Healthcare Quality Improvement
• Patient-Centered Care

Background:

• Routine dialysis care often overlooks patient-identified priorities in interdisciplinary care plans.
• Individualizing care is a growing interest in healthcare, particularly in chronic disease management.

Purpose of the Study:

• To implement and evaluate a person-centered care plan program, "My Dialysis Plan," at a single dialysis clinic.
• To align dialysis care with patient priorities and improve care planning experiences.
• To identify implementation considerations and areas for program improvement.

Main Methods:

• A 6-month quality improvement project with a research substudy involving 49 hemodialysis patients and 14 care team members.
• Utilized the Consolidated Framework for Implementation Research for implementation and evaluation.
• Conducted pre-, intra-, and post-project interviews and compared care plan meeting content and patient-reported outcomes.

Main Results:

• Care teams successfully used "My Dialysis Plan" to elicit and link patient priorities to dialysis care.
• Key implementation elements included interdisciplinary team commitment, accountability, and a structured yet flexible meeting approach.
• Stakeholder input guided program modifications, but follow-up on care plan action items remained challenging; no significant change in patient-reported outcomes was observed.

Conclusions:

• The "My Dialysis Plan" program shows potential for enhancing dialysis care individualization and care plan experiences.
• Further evaluation of the program's impact on patient-reported and clinical outcomes is necessary.
• Single-clinic implementation highlights the need for broader studies.