Healthy Transitions in Late Stage Kidney Disease

Additional education will be provided by nurses to improve communication and reduce fragmentation of care.

Monitor weight to avoid problems related to hypervolemia.

To improve diet and health

Medication will be reviewed by nurses to detect any discrepancies to reduce medication error.

Education will be provided to increase awareness and encourage patients to have advanced directive.

To reduce the number of patients starting dialysis with catheter in place, comprehensive stepwise intervention will be provided by nurses to ensure arterio-venous (AV) fistula placement in all appropriate patients, with coordinated follow up and failure recovery processes.