Improvement in care: a collaborative approach to rehabilitation.

Examination of the patient experience within our unit, from pre dialysis through to establishment of dialysis in the community identified that the care was fragmented. To improve patient care, a change process was initiated. Four home care teams comprising three qualified nurses and one renal care assistant were established with each team responsible for a caseload of patients within a specified geographical location. To measure the impact on the patient, 100 questionnaires were circulated after twelve months. Results from 60 patients showed 76% of pre dialysis patients and 80% of dialysis patients were very satisfied with the change process. The main advantage of this change for the patient is that they are in a continuous supportive cycle for all their non-inpatient care throughout their replacement therapy. We conclude that patient focused care is essential and should be a transition catalyst in a change resistant environment.