For residents living with End-Stage Renal Disease (ESRD), quality care doesn’t just happen in the dialysis chair or at the bedside, it lives in the seamless connections between teams. Clear, consistent communication and effective care coordination between nursing homes and dialysis facilities are essential to delivering safe, efficient, and person-centered care.
When these partnerships work well, outcomes improve. When they don’t, residents are at risk for medical errors, missed treatments, unnecessary hospitalizations, and avoidable suffering. This blog highlights actionable strategies for improving interdisciplinary coordination between your nursing home and external dialysis providers.
Why Communication Matters
Residents with ESRD often have:
- Complex medication schedules
- Frequent lab testing
- Regular hemodialysis or peritoneal dialysis treatments
- Multiple coexisting chronic conditions
- Rapid changes in condition
When information is delayed or incomplete, especially between facilities, care becomes reactive instead of proactive.
Breakdowns in communication can lead to:
- Missed appointments or duplicate treatments
- Medication conflicts (e.g., antihypertensives before dialysis)
- Unrecognized changes in weight or fluid status
- Inadequate response to symptoms like fatigue, confusion, or shortness of breath
Foundations of Effective Communication: Develop a Shared Care Plan
Every resident on dialysis should have a unified care plan that is actively maintained by both the nursing home and dialysis provider. This plan should include:
- Dialysis type and frequency
- Dietary and fluid restrictions
- Medication schedules and adjustments
- Mobility and transportation needs
- Psychosocial considerations and resident preferences
Share this care plan in real time when changes occur, particularly after hospitalizations, medication updates, or a shift in the resident’s condition.
Use Standardized Tools for Handoffs
Handoff tools ensure that important clinical details don’t fall through the cracks. Two useful frameworks include:
- SBAR (Situation, Background, Assessment, Recommendation)
Helps communicate changes in condition or concerns quickly and clearly.
- Interdisciplinary Communication Forms
These can be used to document and share treatment summaries, missed or shortened dialysis sessions, changes in vital signs, or recent lab results.
Designate Point Persons in Both Facilities
- In the nursing home, this could be a nurse manager, MDS coordinator, or social worker.
- At the dialysis center, it might be a charge nurse or care coordinator.
Having a clear liaison helps streamline communication and ensures urgent issues are addressed without delay.
Schedule Routine Interdisciplinary Meetings
Consider bi-weekly or monthly care coordination meetings, either virtually or in person. Invite:
- Patients
- Dialysis nurses or case managers
- Nursing home DONs or care plan team members
- Primary care providers (when possible)
- Social workers and dietitians
Use these meetings to:
- Review recent trends in the resident’s health
- Adjust dialysis prescriptions or schedules
- Discuss care goals, behavior changes, or hospital readmissions
Communication in Emergencies
Clear protocols should be established for:
- Intradialytic complications (e.g., hypotension, chest pain, bleeding)
- Hospital transfers
- Changes in code status or advance directives
- Severe behavioral issues that may interfere with treatment
Ensure staff know:
- Who to call at the dialysis center after-hours
- What documentation to send with the resident to the hospital or dialysis unit
- How to handle non-adherence or treatment refusal in accordance with the resident’s rights
Documentation and Shared Records
Where possible, explore:
- Shared access to electronic health records
- Fax or secure email protocols for sending:
- Vital signs
- Fluid intake/output
- Medication changes
- Psychosocial notes or behavior changes
Even without full integration, consistent documentation and shared forms reduce confusion and increase continuity.
Training and Education
All nursing home staff should receive:
- Basic training on ESRD and dialysis treatment types
- Signs and symptoms to report (e.g., access site issues, swelling, cognitive changes)
- Guidance on dietary and fluid management
- Best practices for pre- and post-dialysis care
Qsource provides educational support and quality improvement resources to help train and equip your team. Visit esrd.qsource.org for toolkits, handouts, and more.