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Renal Connect

Southern NSW Local Health District
Project Added:
2 February 2018
Last updated:
16 February 2018

Renal Connect


South East Regional Hospital (SERH) redesigned its nurse-led Renal Specialist Clinic to ensure it provides more holistic patient and family-centred care.


To ensure all patients attending the Renal Specialist Clinic at SERH have a multidisciplinary assessment within one week, and a self-management plan documented and forwarded to their general practitioner (GP), by July 2018.


  • Increases engagement and support of chronic kidney disease patients.
  • Provides holistic patient and family-centred care.
  • Delivers education tailored to patients’ health, social and cultural needs.
  • Ensures treatments are aligned to the lifestyle and preferences of patients.
  • Improves documentation of patient and family preferences and treatment decisions.
  • Reduces the risk of providing limited information and few treatment options.
  • Improves staff awareness of the psychological and social issues impacting patient decisions and behaviours.
  • Improves communication with GPs.
  • Improves healthcare service efficiency.


Chronic kidney disease is a condition that is characterised by kidney damage or reduced kidney function that persists for more than three months. Treatment will vary, depending on the stage and cause of the kidney disease. This may involve changes to diet or lifestyle, medications, dialysis or a kidney transplant. Doctors perform regular tests, such as blood, urine and imaging tests, to help slow or control progression of the disease.

Prior to the project, chronic kidney disease patients at SERH were monitored via consultations with renal specialists four times a year. Between appointments, they were treated by a renal outreach nurse specialist in five-minute consultations where they had a brief assessment, history take and routine clinical measurement. The focus was on treatment only, with limited attention and capacity to engage patients in personal health goals for families and carers. However, between appointments there was no support or education provided to patients.

This lack of engagement increased the risk of faster disease progression, uninformed treatment choices, reduced awareness of local services and a less than optimal patient journey. In addition, many patients attending the clinics are in an advanced stage of chronic kidney disease. Many start treatment poorly informed about the nature of their condition, risks of treatment and their prognosis.  Few have advanced care plans and communication with the patient’s GP is rare. In addition, referral information often does not contain lifestyle and psychological matters, or education history.


  • Nurse-led patient engagement clinics are held one day a month for patients with an Estimated Glomerular Filtration Rate (eGFR) of less than 30. The clinic starts with a short video on the importance of patient engagement and the purpose of the clinic. This is followed by Health Literacy and Patient Engagement Assessments, as well as the establishment of action plans that are personalised to each patient. This helps the patient develop personal health goals, improve lifestyle behaviours and better understand their health pathway. Goals are documented and revisited at each clinic appointment, to see if patients need additional support to achieve their goals.
  • Multidisciplinary meetings are held via teleconference each fortnight, to discuss patients’ overall health and wellbeing, identify health needs and plan appropriate treatments. Participants include social workers, dietitians, nephrologists, chronic kidney disease coordinators, access coordinators, transplant coordinators, home therapies team representatives and renal outreach staff.
  • A communications strategy will be developed to improve access to information on health services, local contacts in the community and other support services. It may include a website and email newsletters, to build a stronger connection with patients, families and carers.
  • A learning day is currently being developed, to help staff understand their outreach responsibilities and gain hands-on experience with patient engagement clinics. This will ensure staff can take over the role of renal outreach as required. Conferences, forums and workshops in renal care will also be considered for the ongoing professional development of staff.
  • A Bega Valley Kidney Club has been established in partnership with Kidney Health Australia, to provide a support group for patients and ensure they have an advocate for issues and concerns with the service. A consumer group representative has been selected to lead this club, which will be held every three months. Speakers will be invited to discuss relevant topics and discuss positive outcomes and challenges with the service.


Implementation – The project is ready for implementation or is currently being implemented, piloted or tested.


November 2017 – July 2018

Implementation sites

South East Regional Hospital, SNSWLHD


  • ACT Renal Network
  • Kidney Health Australia
  • General Practitioners in SNSWLHD
  • South Eastern NSW Primary Health Network
  • Southern NSW Local Health District


A full evaluation will take place in July 2018, measuring the following outcomes:

  • number of Renal Specialist Clinic patients with multidisciplinary assessments completed within one week
  • number of Renal Specialist Clinic patients with a self-management plan documented
  • number of Renal Specialist Clinic patients who have their management plan forwarded to their GP.

Lessons Learnt

  • It is important to identify the needs of the patient and any gaps in their care. The patient journey should be understood by the patient, their family or carer, and the healthcare team.
  • Patience is critical to the success of this project. In this case, a change in approach was required to engage patients and map the patient journey.
  • Staff resourcing was a challenge, as the team needed to work on the project in addition to their normal responsibilities. However, a passion for the cause motivated them to find the time and maintain momentum.


Jan Stanley Diaresco
Clinical Nurse Specialist
SNSWLHD Renal Services
Southern NSW Local Health District
Phone: 02 6491 9384

Linda McCorriston
Clinical Nurse Consultant
Southern NSW Local Health District
Phone: 02 6495 8303

Checille Naig-Esma
Nurse Unit Manager, Renal Dialysis Unit
South East Regional Hospital
Southern NSW Local Health District
Phone: 02 6491 9383

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