Theme 1: Bridging Community and Acute Care
UPTAKE
Using Personalized risk and digital tools for Transitions in care after Acute Kidney Events
Lead:
Matthew James
Co-Lead:
Neesh Pannu
Project Coordinator:
Nusrat Shonmu
INNOVATION STAGE
Evaluation of Prototype
Health Innovation Focus
Chronic Disease
Population and Setting
Adults
Technology and Intervention
Data Modelling, Platform and Dashboard Visualization
BENEFITS
For Users
Patients gain greater awareness and understanding of their AKI diagnosis, along with clear, actionable steps for post-discharge care. The personalized guidelines enhance their confidence in managing follow-up appointments, medications, and lifestyle adjustments, reducing the risk of serious complications and improving overall quality of life.
For The System
For the healthcare system, this intervention helps reduce hospital readmissions by empowering patients to manage their condition effectively at home. By minimizing complications associated with unmanaged AKI, the intervention lowers healthcare costs, optimizes resource use, and supports patient-centered care. This model of personalized discharge planning could be adapted for other conditions, demonstrating scalable, preventative, and innovative healthcare practices.
Project Theme Information
Acute Kidney Injury (AKI) is a serious condition that can cause long-term complications, including cardiovascular issues and recurrent hospitalizations. AKI often develops rapidly, and if not managed properly, it can lead to lasting health problems. A critical gap exists in care continuity from hospital to home, as many patients with AKI are unaware of their condition or lack guidance on follow-up care, which increases the risk of severe health outcomes.
This is a patient-specific educational and guidance platform designed to support AKI management after hospital discharge. It provides a tailored after-visit summary that includes AKI-related information, customized follow-up instructions, and preventive guidelines, enabling patients to manage their health proactively. By delivering personalized, condition-specific discharge documentation, the platform aims to improve continuity of care and patient awareness.
At the point of discharge, the clinical team creates and delivers a personalized AKI-focused summary to the patient. This document includes essential information on AKI, customized recommendations for medication management, blood work follow-up, and lifestyle changes. The summary educates patients about their specific health risks and outlines actionable steps to manage AKI and reduce complications.
View other projects and explore the Health Everywhere Portfolio to see how local innovations are transforming care across the province.
Explore the Health Everywhere Portfolio to see how local innovations are solving real-world challenges and shaping the future of care across the province.
ABOUT
The Health Everywhere Hub portfolio map showcases academic-led projects tackling real healthcare challenges across Alberta. By highlighting shared goals and commonalities, we hope to spark collaboration and amplify impact across the system.
It’s more than a list of projects - this evolving collection shows what’s possible when partnerships, bold ideas, and real-world testing come together.