A Risk-Informed Transitional Care Framework for Patients with Glomerular Disease.

Area of Science:

• Nephrology
• Healthcare Management
• Patient Care

Background:

• Patients with glomerular disease (glomerulonephritis, GN) experience complex care transitions.
• These transitions increase risks of fragmented care, delayed decisions, and poor preparedness.
• A standardized approach was lacking for key transitions like transplant referral, dialysis planning, and pediatric-to-adult care.

Purpose of the Study:

• To describe the design, core components, and implementation of the PATHWAY GN protocol.
• To introduce an interdisciplinary transitional care model for glomerular disease.
• To highlight a collaborative nurse-physician approach for enhanced patient support.

Main Methods:

• Development of the PATHWAY GN protocol, an interdisciplinary transitional care model.
• Integration of the protocol into routine nephrology practice within the Mid-Atlantic Glomerulonephritis Network (MAGNET).
• Focus on a nurse-physician collaborative strategy for patient identification and transition support.

Main Results:

• The PATHWAY GN protocol was designed as a standardized approach for complex care transitions.
• It addresses key transition points including transplant referral, dialysis planning, and pediatric-to-adult care.
• The model emphasizes interdisciplinary collaboration for care coordination and patient engagement.

Conclusions:

• The PATHWAY GN protocol provides a structured model to support patients with glomerular disease through critical care transitions.
• An interdisciplinary, nurse-physician collaborative approach enhances care coordination and patient preparedness.
• Standardized transitional care models are essential for improving outcomes in glomerular disease management.