IPCHS. Integrated People-Centred Health Services


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A transition of care is defined as a change in level of health care services, as patient care needs change from one location to another during acute or chronic illness. The location of services can vary from the hospital, skilled nursing facility, an outpatient setting, a primary care provider's office, or home health. Care coordination gaps can occur due to a lack of information exchange through the electronic health record, a lack of evidence-based standards, and poor communication among providers. Often, clinicians work with a silo mentality, resulting in poor health outcomes and negatively impacting the patient care experience. Patients with chronic kidney disease (CKD) are vulnerable to suboptimal integrated care coordination during transitions of care, as individuals seek treatment from diverse practitioners within multiple settings to meet their medical needs. This article discusses methods to improve integrated care, emphasizing the use of technology-based interventions to facilitate care transitions for patients with CKD.


Nephrology Nursing Journal