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Transition Guides for Care Teams & Patients

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Submission from Janet Williams, Project Manager 

Name of the tool or resource: 

Transition Guides for Care Teams & Patients

Were you involved in developing the tool? : 

Yes


What is the purpose of the tool?:

Every kidney patient’s health journey includes major transition points. This may include starting treatment for kidney failure, changing the type of treatment received or choosing to end treatment all together. Each change can cause stress and fear for patients. In collaboration with health authority partners and patients, we developed a series of guides to help prepare patients, families and care teams for these transitions.   
                                         
The care team guides were designed to guide staff through the steps and activities of transition with allocation of responsibility and communication/information flows. The patient guides were designed to provide a step-by-step roadmap for patients and families to guide them through the transition process and encourage active participation in the process.


What were some highlights and challenges of developing the tool?

Highlights: 
We worked closely with patients to define and refine the content in each of the patient guides.  We also pilot tested the peritoneal (PD) and home hemodialysis (HHD) patient guides and systematically reviewed the results as part of our evaluation process. We've submitted an article for publication about our process, outcomes and learnings. 
 
Challenges: 
Care teams are really busy, so getting input from all modality teams on the guides (care team and patients) took time. It will also take time to incorporate the guides into everyday practice across the programs.


What benefits have you seen after using the tool?

Quotes from patients after the pilot test: 

 “I’ve always been a planner. When things are planned well in advance, I feel much less anxious about the future.” ~Jan
 
 “This document expresses caring and assistance and it has a reassuring tone, which is helpful to me as I think about my options.”~ Dennis
 
 “This document has helped me think about my future. Even though I am not there yet, I am glad I have this information.” ~Dolly


Additional Comments: ​

All the guides can now be accessed on the BC Renal website in both the Health Info  and the Health Professionals sections. 

Start-up kits, including copies of the guides and posters, were also distributed to every hemodialysis unit (incentre and CDU), kidney care, peritoneal dialysis (PD) and home hemodialysis (HHD) clinic in BC. 


 
 

 

 

SOURCE: Transition Guides for Care Teams & Patients ( )
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