A Risk-Informed Transitional Care Framework for Patients with Glomerular Disease.

Abstract

Patients with glomerular disease (glomerulonephritis, GN) experience complex care transitions that increase the risk of fragmented care, delayed decision-making, and inadequate preparedness. Within the Mid-Atlantic Glome rulonephritis Network (MAGNET), an interdisciplinary nephrology care team identified the absence of a standardized approach to support patients across key transition points, including transplant referral, dialysis planning, and pediatric-to-adult care. In response, the PATHWAY GN protocol was developed as an interdisciplinary transitional care model embedded within routine nephrology practice. This article describes the design, core components, and implementation strategy of PATHWAY GN, highlighting a nurse-physician collaborative approach to patient identification, transition support, care coordination, and engagement in glomerular disease care.