Dr. Frank O’Brien will head transitional care team to reduce rates of hospital readmission for dialysis patients.
Congratulations to Frank O’Brien, MD, assistant professor of medicine, Division of Nephrology, who is the recipient of a Project Award from The Foundation for Barnes-Jewish Hospital. Dr. O’Brien, received the two-year, $120,000/year award to integrate the care of WashU dialysis patients while admitted to BJH and devise a personalized transitional care protocol to prevent hospital readmission.
The average 30-day readmission rate for patients with end-stage renal disease (ESRD) on dialysis patients is 39%, compared to approximately 15% of all hospitalized patients in the general Medicare population. Frequent hospital readmissions contribute to high mortality rates and poor health-related quality of life of ESRD patients, and are costly, as well, to the dialysis unit and hospital involved. In the past decade, there has been a major push to decrease readmission rates.
O’Brien’s grant addresses the high 30-day readmission rates of our dialysis patients. “Improving the readmission rates for BJH and dialysis centers will require direct monitoring, enhanced communications between providers and patients, specific and focused patient education, and interactive provider interventions,” says O’Brien. A modified transitional care program to reduce readmission rates in patients on home dialysis will also be put into place.
Key to the program is a transitional care team consisting of a lead physician, nurse coordinator and social worker who will work with specific staff at the out-patient dialysis unit. “The team will reconcile each patient’s hospital admission, increase MD visits in the week post discharge and improve communication between the inpatient nephrology team and outside dialysis facilities,” says O’Brien.
The transitional care team includes: Ellen Criswell, RN, Inpatient Clinical Nurse Coordinator; Melissa “Missy” Rocco, MSW, LCSW, Inpatient Social Worker; Vicki Haldaman, RN, BSN, Clinical Nurse Coordinator; and Jamie Miles, Administrative Coordinator at the WashU Dialysis Center at Forest Park.
Members of the team will meet with a patient prior to discharge from BJH to organize post-hospital follow-up visits, review medications and discuss their discharge summary. The team will also collaborate with the in house social workers to ensure that each patient has a safe discharge plan and that transport is set up for the patient to their next dialysis clinic visit.
“Patient care requires a strong team, all of whom innovate to improve,” O’Brien points out. “We are grateful to The Foundation for helping us further this goal.”
Dr. Frank O’Brien highlighted in Nephrology Spring 2019 Newsletter
O’Brien’s dedication to reducing the number of hospital readmission rates for our dialysis patients was detailed in the cover story of the Division of Nephrology’s Spring 2019 Newsletter. He is also involved with ongoing studies aimed at improving care among our ESRD patient population. Most notably, O’Brien recently received a Clinical Innovation Grant to study the effect of intra-dialytic potassium and magnesium fluctuations on cardiovascular functioning in ESRD patients undergoing in-center hemodialysis.
With the merger of Barnes Hospital and Jewish Hospital in 1996, The Foundation for Barnes-Jewish Hospital was established, continuing the rich history of philanthropy known to both institutions. Follow the links to read more about The Foundation and its Project Awards.
Find Dr. O’Brien on Twitter @frankjobrien84.