Quality improvement through the introduction of interdisciplinary geriatric hemodialysis rehabilitation care

Background: Provision of rehabilitation with the aim of restoring personal independence in elderly hemodialysis patients faces several challenges. Design: Quality improvement report. Setting & Participants: First 3 years of experience of an inpatient geriatric hemodialysis rehabilitation program in Toronto. Patients with new-onset disability from prolonged illness or an acute event rendering them incapable of living independently. Quality Improvement Plan: Provision of in-patient rehabilitation with on-site dialysis; a simplified referral system; preferential admission of elderly dialysis patients; short daily dialysis sessions; integrated multidisciplinary care by experts in rehabilitation, geriatric medicine, and nephrology; and reciprocal continued medical education among staff. Measures: Outcome measures were percentage of patients discharged home, score on the Functional Independence Measure, and attainment of rehabilitation goals. Results: In the first 36 months, 164 dialysis patients aged 74.5 +/- 7.8 years were admitted. On admission, patients had a mean Charlson comorbidity score of 7.8 +/- 2.5, 98% had difficulty walking, and 84% required help with bed-to-chair transfers. After a median of 48.5 days, 111 patients (69%) were discharged home; 15 patients (9%), to an assisted-living setting; 20 patients (12%), to a long-term care facility; and 18 patients (11%), to other facilities for acute or palliative care. Of those completing therapy, 82% met some or all of their rehabilitation goals. Limitations: The program relied on the leadership and drive of key personnel. Discharge disposition as an outcome can be affected by many factors, and definition of attainment of rehabilitation goals is arbitrary. Conclusion: The introduction of an integrated dialysis rehabilitation service can help older dialysis patients with new-onset functional decline return to their home.