intensive patient referral and education program prior to renal replacement therapy

Conditions: Chronic Kidney Disease; Hypertension

Summary: intensive patient referral and education program prior to renal replacement therapy (iprep-rrt) is a 12-week intervention that identifies hospitalized african americans with advanced chronic kidney disease (ckd) and provides them with hospital- and community-based education, navigation and self-management support. participants will be randomized to the iprep-rrt intervention versus enhanced usual care.

the intensive patient referral and education program prior to renal replacement therapy (iprep-rrt) will determine the efficacy of the hospital-based patient intervention (hpi) in improving patient knowledge, self-efficacy, and intent for chronic kidney disease (ckd) self-management and renal replacement therapy (rrt) planning; and 2) determine the efficacy of the community-based patient intervention (cpi) during a 12 week outpatient follow-up program that combines outpatient follow-up with multiple modes of communication (in-person session, phone calls and personalized text messaging) and navigation in increasing participants' initiation and maintenance of ckd self-management and rrt planning, compared to enhanced usual care (attention controls). the goal is to improve knowledge and outcomes for african american patients with advanced ckd through the iprep-rrt. to accomplish this goal, investigators will 1) determine the efficacy of the hospital-based patient intervention (hpi) in improving participant knowledge, self-efficacy, and intent for ckd self-management and rrt planning; and 2) determine the efficacy of the community-based patient intervention (cpi) during a 12 week outpatient program that combines outpatient follow-up with multiple modes of communication (in-person session, phone calls and personalized text messaging) and navigation in increasing initiation and maintenance of ckd self-management and rrt planning, compared to enhanced usual care. to that end, investigators will conduct a one-site randomized controlled trial, where participants will be randomized in a 1:1 ratio into either the intervention (iprep-rrt) or control groups (enhanced usual care). the randomization will be stratified by baseline blood pressure (controlled or uncontrolled). participants will receive 2 in-person education sessions (during hospitalization and week 12), phone sessions at weeks 4 and 8, and weekly personalized text message contact. the duration of the intervention will be 12 weeks, and participants and controls will be assessed pre-intervention, immediately post-hospital based intervention, at 4 ,8 and 12 weeks during community-based intervention and 4 weeks post-intervention (16 weeks).

Eligibility criteria:
inclusion criteria: * patients over the age of 18 and under 70 * admitted to the university of chicago inpatient general medicine service * likely hospital stay greater than 48 hours * diagnosis of advanced ckd (stage 3b or above, as determine by problem list, icd- 10 codes or egfr\<45 during admission and from previous medical encounters) * self-identify as black or african american exclusion criteria: * non-english speaking * unable to communicate due to current medical status * unable to consent due to mental status * expected hospital stay less than 24 hour * current admission in icu

Keywords: hospitalized patients african american motivational interviewing