Hospitalization Reduction

Reduce Hospital Admissions, Readmissions, and Outpatient Emergency Visits

Improving and Maintaining the Health of ESRD Patients

There are numerous reasons a dialysis patient may not be able to achieve and maintain optimal health. Health deficits may be related to health conditions, such as but not limited to, anemia, diabetes, cardiovascular disease, or diagnosed and undiagnosed mental health issues. Health deficits may be related to patient behavior, such as but not limited to, not taking medication as prescribed, failure to attend check-ups, eating an unhealthy diet, smoking tobacco, using recreational drugs, excessive alcohol use, lack of exercise, or missing or shortening dialysis treatment. Health issues may be related to an unstable social support system and/or financial problems, such as but not limited to, access to food, shelter, transportation, clothing, medication, medical care, and/or emotional support, making patients potentially unable to care for themselves.

Hospitalization Avoidance
If you have questions or need assistance, please contact us:

Tools & Resources

Patient Education

Provider Education

  • How Are You Feeling Today? Zone Tool: English
  • We're Not Nosy--We Care: English | Spanish
  • Transitions Champion Interview: Checklist
  • A Change Package to Reduce Hospitalizations: PDF
  • Forming Communities of Practice to Reduce Hospitalizations/Readmissions and Emergency Room Visits in the ESRD Population: PowerPoint