Table 1.

Processes likely to be most important for reducing rehospitalization of patients on dialysis

Posthospitalization ProcessRationaleMost Appropriate Responsible Party
(1) Reassessment of dry weightDuring hospitalizations, patients on dialysis frequently experience weight changes; with prolonged hospitalization, there may be significant loss of lean body mass; failure to readjust dry weight may be a leading cause of readmissions related to volume overloadNephrologist or a midlevel practitioner
(2) Medication reconciliationChronic medications are often changed in the hospital, and inadequate reconciliation may result in therapeutic deletions, duplication, or dosing errorsIdeally nephrologist or a midlevel practitioner; can be a registered nurse
(3) Assessment of recovery from the acute illness and current medical stabilityWith today's relatively short hospitalizations, it is important to assess for complete recovery from the acute illness; failure to recognize ongoing symptoms and signs may lead to readmissionNephrologist or a midlevel practitioner
(4) Determination of necessary medical and other follow-upPosthospital follow-up with other physicians or related medical services may be indicated; assessment of need for follow-up and insurance that follow-up is completed may reduce readmission riskIdeally nephrologist or a midlevel practitioner; can be registered nurse