SummaryThe Emory Transplant Center required kidney transplant candidates to complete an onsite education class before receiving a medical assessment. Designed to maximize patient interaction and engagement, the 3-hour session consisted of presentations and discussions about medical issues and concerns, the patient's financial responsibilities, and life after the transplant. The class significantly increased the percentage of patients completing the transplant evaluation process, particularly among African American patients and people of lower socioeconomic status. In the spring of 2011, the center replaced the inhospital education class with an online version that patients must complete at home or at the hospital before proceeding with their medical evaluation.Moderate: The evidence consists of pre- and post-implementation comparisons of the proportion of transplant candidates completing the evaluation process before and after implementation of the mandatory class; the data compare 845 patients who started the process before implementation to 281 patients who did so afterward.
Developing OrganizationsEmory Transplant Center
Date First Implemented2007
Race and Ethnicity > Black or african american; Vulnerable Populations > Impoverished; Racial minorities
Problem AddressedMany kidney transplant candidates (particularly African Americans and people with lower socioeconomic status) fail to complete the evaluation process and never receive a transplant, due in part to inadequate patient education and engagement. Education programs often do not fully engage patients or provide enough opportunities to ask followup questions, leading to patients receiving incomplete or confusing information and then deciding to drop out of the process.
- High drop-out rates, particularly among African Americans and people with lower socioeconomic status: A significant percentage of patients referred to transplant centers drop out before being placed on the transplant list. Drop-out rates among African Americans and people of lower socioeconomic status are significantly higher than among whites and higher socioeconomic groups. One study found that African Americans with end-stage renal disease were up to 59 percent less likely than their white counterparts to get a transplant,1 while another found that people in the lowest socioeconomic quartile were significantly less likely than those in the highest quartile to receive a transplant, especially one from a living donor.2 At the Emory Transplant Center, more than half of all patients failed to complete the pretransplant evaluation process prior to implementation of this program.
- Driven by inadequate patient education and engagement: Patients drop out of the transplant process for many reasons, including but not limited to missing followup appointments, failing to secure adequate financing, or deciding post-transplant regimens are too onerous. At many transplant centers, the high dropout rate stems in part from inadequate patient education and engagement on topics such as medication, nutrition, weight control, and financial issues. Patients who demonstrate health literacy in these areas are more likely to complete the enrollment process, adhere to medication regimens, and achieve good posttransplant outcomes.2 Yet many transplant centers (including Emory before implementation of this program) provide education in an informal, uncoordinated way, typically on a one-on-one basis between medical appointments and tests. As a result, patients and family members often miss important points and end up feeling overwhelmed and/or confused. This approach also limits opportunities to ask followup questions and meet other patients sharing similar experiences.
Description of the Innovative ActivityThe Emory Transplant Center required kidney transplant candidates to complete an onsite education class before receiving a medical assessment. Designed to maximize patient interaction and engagement, the 3-hour session consisted of presentations and discussions about medical issues and concerns, the patient’s financial responsibilities, and life after the transplant. A detailed description of the class and related issues follows:
- Mandatory first step: Patients completed a 3-hour onsite education program as the first step in the transplant process, before the medical evaluation to determine suitability for transplant. After being referred to Emory (usually by their nephrologist or primary care doctor), a medical secretary informed the patient about the mandatory class and scheduled a time for them to attend. Patients who agreed to attend received an information packet in the mail that outlined the course content and other relevant information. The mailing also encouraged patients to bring up to two family members or friends. Patients who declined could not proceed with the transplant process.
- Classroom experience designed to maximize engagement: Emory structured the classes to make them easily accessible to patients and to maximize their ability to understand and engage in the content. Key aspects of the class are outlined below:
- Convenient schedule: Emory offered the class 1 day each week, with the day varying to guarantee that patients on dialysis could find a day that worked for them.
- Class size to promote sharing of experiences: The typical class included 10 to 12 patients and an equal number of family members or friends. This size allowed patients to see and share experiences with others like them going through the transplant process, something that is especially important for patients with lower education and health literacy.
- Content focused on major issues, with ample opportunity for interaction: The 3-hour course covered three major areas, each for roughly 50 minutes, with breaks in between. (See below for details.) Throughout the class, session leaders encouraged attendees to ask questions, raise issues, and engage in discussions with the teachers and each other; they also provided contact information so that attendees could call afterward with any followup questions.
- Medical issues: A transplant coordinator led a discussion of medical issues, including different types of transplants (i.e., living and deceased donor), the pretransplant medical evaluation, the surgery, the postsurgical inpatient stay, immunosuppressant medications, potential complications, and postsurgical health issues.
- Financial considerations: A financial coordinator reviewed and answered questions about the patient’s financial responsibilities, including what costs insurance does and does not cover, nonmedical costs (e.g., plane fare, lost wages), and opportunities for fundraising and financial assistance.
- Life after the transplant: A social worker discussed life after the transplant, including its potential effect on relationships with family and friends, mental and physical health, and productivity at work. He or she also reviewed a list of community agencies and organizations that offer social, legal, and financial support to patients.
- Patient declaration of intended next step: The class concluded with a brief review of the next steps in the path to a transplant. Patients received information packets containing a one-page "letter of intent" that had to be completed before continuing the process. (Patients could either fill out the form at the conclusion of the class or take it home with them and send it later by mail or fax.) The letter offered two options:
- Not interested: Patients could sign a declaration indicating they had attended the class, had received information about transplant listings and waiting times, and were "not interested in a transplant at this time."
- Want to continue: Patients could sign a declaration indicating they wanted to continue with a transplant evaluation. Signing this declaration meant agreeing to be active in their care during the transplant process and to participate in the paired-donor exchange program if they had a living donor who was not a match for them. After signing the form, patients could schedule their medical evaluation. The medical secretary monitored incoming forms to ensure that patients did not schedule further appointments until they had sent in the form.
Context of the InnovationLocated in Atlanta, the Emory Transplant Center provides hand, heart, kidney, liver, lung, and pancreas transplants. It is the only center offering multiple types of transplants in Georgia. Roughly two-thirds (65 percent) of patients referred to the center are African American or Hispanic. The impetus for the mandatory education class came from transplant center staff, who noticed that many patients referred to the center failed to complete the evaluation process. They believed that inadequate education was a major factor driving the high dropout rate; as noted earlier, Emory physicians and staff often discussed critical transplant issues with patients between tests and appointments, leaving little time or opportunity to ask questions. As a secondary motivation, the team also expected the class would be less labor-intensive than the existing education model, since it brought together groups of patients for formal education (rather than each patient receiving separate one-on-one education).
ResultsThe mandatory inperson class significantly increased the proportion of patients completing the evaluation process, with greater improvements among African Americans than whites and people of lower socioeconomic status than people of higher socioeconomic status.
Moderate: The evidence consists of pre- and post-implementation comparisons of the proportion of transplant candidates completing the evaluation process before and after implementation of the mandatory class; the data compare 845 patients who started the process before implementation to 281 patients who did so afterward.
- More patients completing evaluation: 80.4 percent of patients who attended the class completed the evaluation process, well above the 44.7 percent of potential transplant candidates (i.e., those referred to the center) who did so prior to implementation.
- Greater improvements among African Americans: 79.8 percent of African Americans who attended the class completed the evaluation process, nearly double the 41-percent rate before implementation. (The corresponding post-implementation figure among whites was 81.6 percent, up from 49.7 percent.) Program implementers attributed the increased visibility of other African Americans going through the transplant education process as an important factor in the increased participation of African American patients.
- Greater improvements among people of lower socioeconomic status: 80.7 percent of people from high-poverty neighborhoods (i.e., neighborhoods with more than 20 percent of residents living below the Federal poverty line) who attended the class completed the evaluation process, more than double the 34.5 percent rate among people from high-poverty neighborhoods before implementation. Similarly, the completion rate among people with less than a high school education was 73.9 percent in the post-implementation group, compared to 28.8 percent before implementation.
Planning and Development ProcessKey steps included the following:
- Team decision to introduce mandatory class: In the spring of 2007, senior members of the center’s 20-person transplant team (which includes surgeons, transplant physicians, social workers, transplant coordinators, pharmacists, nutritionists, and nurses) proposed the idea of the mandatory class at one of the team’s weekly meetings. After some discussion, team members unanimously agreed to move forward with the idea. They also decided to require those completing the course to sign a letter of intent afterward before proceeding with the medical evaluation.
- Creation of class material: Over the next several months, team members worked together to turn information they already provided to patients during informal one-on-one meetings into a more formal presentation.
- Initial introduction and modifications: The team introduced the class in September 2007. The initial version took 4.5 hours to deliver, which proved too much for some patients to handle. Over the next several months, presenters made minor changes to the content based on patient responses to the material, including streamlining it 3 hours.
- Introduction of online version: In the spring of 2011, the center revised its enrollment process and stopped offering the inhospital education class. Instead, the medical secretary now asks patients to complete an online version of the class (offered through an outside company) before they come to the center for their medical evaluation. If patients fail to do so (typically because they lack internet access or are uncomfortable with home computers), staff arrange for them to complete the online version at the hospital when they arrive for the medical evaluation. Patients must complete the class before proceeding with the evaluation. The online option works well for the many patients who live far away from the center, and it tends to be less time-intensive (and thus less costly) for the center.
Resources Used and Skills Needed
- Staffing: A number of transplant coordinators, financial coordinators, and social workers participated in teaching the classes.
- Costs: Data on program costs are not available, although the primary expense consisted of staff member time to teach the courses. Development costs were minimal since the team used existing content to create course materials.
Tools and Other ResourcesAdditional information about the transplant center and its enrollment process can be found at: http://www.emoryhealthcare.org/transplant-kidney/index.html.
Getting Started with This Innovation
- Include family members: Encourage patients to bring family members to the class. In Emory’s experience, family members often raised important questions about the transplant process.
- Offer class on varying days: Most patients seeking kidney transplants get dialysis several times a week on days that vary from week to week. Since patients cannot attend class on these days, it makes sense to vary the day(s) the class is held each week.
- Single out "star" educators: Team leaders should identify staff with an aptitude for teaching and offer them the chance to lead more classes than those who do not like to teach and/or who prefer one-on-one interactions with patients.
- Use a diverse team: Patients will likely feel more comfortable and learn more if they can easily relate to those teaching the class. Consequently, teachers should, to the extent possible, have racial and/or ethnic backgrounds similar to those of patients attending the session.
Sustaining This Innovation
- Monitor and report on program's impact: Monitoring the program's impact on dropout rates helps to gauge its effectiveness, maintain leadership support, and facilitate modifications to improve the course over time. More detailed data, such as a breakdown of the dropout rate by race, age, and/or gender, may also be helpful, as might eliciting patient views on the benefits and drawbacks of the class.
- Streamline content over time: Transplant candidates and their families need to understand a large amount of information related to a wide variety of topics. However, their attention may lag after several hours. Consequently, those teaching the course need to periodically evaluate and, as necessary, revise the content to keep it concise and relevant. Having team members with a background in education may help with this task. As noted earlier, Emory shortened the original 4.5-hour course to a 3-hour condensed version; team members believe this version was more effective than the original.
- Consider offering online and in-person versions: As noted, Emory discontinued the inperson class in favor of an online offering. Emory program leaders believe that the best approach—if financially feasible—is for transplant centers to offer both online and inperson versions with identical content.
Contact the InnovatorRachel Patzer, PhD, MPH
Emory University School of Medicine
Department of Surgery
Emory Transplant Center
101 Woodruff Circle WMB #5125
Atlanta, GA 30322
Jennie P. Perryman, RN, PhD
Director, Policy and Outcomes Management
Emory Transplant Center
1762 Clifton Road, NE
Atlanta, GA 30322
Innovator DisclosuresThe work described here was funded by grants from the NIDDK and HRSA/DOT, which paid for a portion of Ms. Perryman's salary, as well as a grant from the Emory Race and Difference Initiative, which was used to fund student data abstraction.
Ms. Perryman is a founding and current Board Member of the Georgia Transplant Foundation.
References/Related ArticlesPatzer RE, Perryman JP, Pastan S, et al. Impact of a patient education program on disparities in kidney transplant evaluation. Clin J Am Soc Nephrol. 2012 Apr;7(4):648-55. [PubMed]
Patzer RE, Perryman JP, Schrager JD, et al. The role of race and poverty on steps to kidney transplantation in the southeastern United States. Am J Transplant. 2012;12:358-68. [PubMed]
Axelrod DA, Dzebisashvili N, Schnitzler MA, et al. The interplay of socioeconomic status, distance to center, and interdonor service area travel on kidney transplant access and outcomes. Clin J Am Soc Nephrol. 2010 Dec;5(12):2276-88. Epub 2010 Aug 26. [PubMed]
Gordon EJ, Wolf MS. Health literacy skills of kidney transplant recipients. Prog Transplant. 2009 Mar;19(1):25-34. [PubMed]
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Original publication: July 18, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: June 18, 2014.
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Date verified by innovator: June 06, 2014.
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