PROJECT SUMMARY/ABSTRACT Acute kidney injury (AKI) confers a significant risk of poor short- and long-term health outcomes, with 49% of survivors re-hospitalized within 1 year, a 1.5-2.5-fold higher risk of chronic kidney disease and1.4-fold higher risk of cardiovascular events. This significant risk of poor outcomes can be partially attributed to gaps in kidney-focused care and education during transitions. Nephrotoxin use remains highly prevalent in AKI survivors, which is a potential modifiable determinant of long-term outcomes. With existing models, 30% of patients who survive an episode of moderate to severe AKI fail to receive a serum creatinine check and a clinic visit in the 30-days after discharge, two core components of adequate kidney follow-up. There is a critical need to develop new transitional care models for AKI survivors and to evaluate their impact on clinical and patient- centered outcomes. To address this need, the overall goal of this proposal is to enhance post-AKI care quality, outcomes, and experience through the AKI in Care Transitions (ACT) program. ACT is a bundled intervention that includes early identification of high risk AKI survivors with an electronic indicator, nurse education and care coordination prior to hospital discharge, with a post-discharge follow-up visit within 7-14 days by provider and pharmacist in the patient’s medical home, primary care. The proposal aims to 1) Determine the preliminary efficacy of the ACT program to improve clinical and patient-reported outcomes and, 2) Evaluate the feasibility and acceptability of the AKI in Care Transitions pilot and iteratively refine the intervention. In Aim 1 we will conduct a pilot pragmatic clinical trial in 50 AKI survivors. Patients will be randomized 1:1 to either the ACT intervention or usual care. The primary outcome assessed in an intention-to-treat analysis will be kidney knowledge and secondary patient reported and clinical outcomes to be measured in the 6-months after discharge will include health literacy, quality of life, hospital readmissions, recurrent episodes of AKI, kidney function, and nephrotoxin use. Aim 2 uses a convergent mixed methods study design to evaluate the feasibility and acceptability of the ACT intervention from the perspective of patients and clinicians. Feasibility will be measured by proportion of patients who complete each aspect of the ACT workflow, and acceptability will be characterized with 20 qualitative interviews and direct observation of 10 nurse education and follow-up visits. The ACT intervention will be iteratively refined based on these insights to reduce potential barriers to implementation in a larger trial or clinical practice. This innovative proposal uses an efficient, coordinated, care transition model to enhance kidney health, knowledge, and safety in a high risk group of patients with existing gaps in care quality. The ACT pilot is directly aligned with the AHRQ mission to make healthcare safer, of highe...