Grant: Team Grant: Transitions in Care

Nearly one in ten people who are hospitalized in Canada develop a complication with sudden loss of kidney function, called acute kidney injury (AKI). AKI may lead to other severe health problems after discharge home, such as kidney failure requiring dialysis treatment, heart failure, heart attacks, stroke, and even premature death. Discharge from hospital to home can be a difficult transition where there are often gaps in identification, communication, care coordination, education, and planning of care for AKI. Our study team will co-design and evaluate a tailored post-discharge care plan that is based on the risk of later kidney problems and uses currently available, yet untapped digital innovation to improve the health and experience of people with AKI. This study will be built into Alberta's new provincial electronic health record, called Connect Care. Our plan is to use digital tools in Connect Care to identify all people in Alberta hospitals that have had an AKI event and are at increased risk of long-term complications. Half will randomly bed assigned to receive a tailored care plan based on their risk at hospital discharge while the other half will receive care as it is currently provided by their healthcare team. Connect Care will automatically calculate a patient's risk and report this risk in their chart along with recommendations for care. Our study team includes patients, healthcare providers, and health system decision makers needed to co-develop our proposed strategy and introduce the changes needed to deliver this intervention. We will study whether this strategy can reduce health problems that may happen after AKI including death, need for dialysis, heart attacks, and stroke. We will also determine if the approach improves patient experience during the transition from hospital to home. Our study has the potential to revolutionize how we care for people that leave hospital after having AKI.