Patients with Chronic Kidney Disease (CKD) have complex clinical needs and multiple co-morbid conditions. Only a few of these patients receive dialysis, however with or without dialysis, there are high rates of death, predominantly due to cardiovascular conditions. The last year of life is crucial for these patients, having multiple hospital admissions, issues of frailty and displacement from their home environment. Unwillingly, the majority die at hospital and recurrent clinic visits are very distressful for patients, carers and family members.
This project plans to resolve these issues and bring back dignity for those who are dying from CKD. The Renal Support Care Clinic (RSCC) provides multidisciplinary care for patients via a core team consisting of a Nephrologist, CKD Nurse, Social worker, Dietitian, pharmacist and other opportunistic allied health team members as and when required.
The project has successfully navigated healthcare system challenges to deliver change, improvement and innovation in their own health service and was presented at the Clinical Excellence Queensland Showcase 2019.