# Transitions of care program to make guideline-based recommendations actionable for patients with diabetic kidney disease (TOGA-DKD)

> **NIH AHRQ R03** · ALBERT EINSTEIN COLLEGE OF MEDICINE · 2024 · $100,000

## Abstract

PROJECT SUMMARY
TOGA-DKD is a pilot/feasibility study of the use of hospitalization as an opportunity to identify patients
with high-risk diabetic kidney disease (DKD) and link them to a pharmacist-led transition of care (TOC)
program to ensure access to guidelines-based medications post-discharge. Kidney disease affects up
to 37 million Americans, 800,000 of whom have end stage kidney disease (ESKD). DKD is the leading
cause of ESKD, is a major risk for mortality and disproportionately affects racial-ethnic minorities. New
therapies have revolutionized treatment of DKD and adherence to updated guidelines can save lives.
However, implantation challenges prevent adherence to guidelines in those patients that need them the
most, patients like ones served by Montefiore Health System. Frequent hospitalizations and a
fragmented healthcare delivery system that enables clinical inertia, both of which are worsened by
unmet social needs, exacerbate DKD progression in minoritized populations. Transitions between
hospital and discharge site, and patients and their community networks, are far from seamless,
rendering patient self-management and adherence to guideline-recommended care challenging.
Pharmacists have the necessary skillset to overcome these challenges because of their ability to
interface with patients, navigate complicated formulary requirements, titrate medications according to
clinical findings, and coordinate care with health care providers. Hospitalization presents an opportunity
for pharmacists to implement initiation of these medications while providing transition of care coaching.
This study will test the feasibility of adapting a transition of care program already embedded in the
institutional mission to reduce readmissions among heart failure patients, to meet the population health
goal of reducing kidney disease progression. An essential component of the pharmacist intervention is
determination of social needs of patients, a necessary part of any effort to reduce health disparities,
using the validated Montefiore Social Needs Screener. We will test recruitment feasibility of 100 patients
by 2-3 pharmacists within 7 months, because this is a pilot study to inform a large multicenter
randomized controlled trial that tests the effectiveness of TOGA-DKD to improve adherence and reduce
DKD progression. Process outcomes testing will help determine best workflow strategies of the
pharmacist and coordination efforts among multiple ambulatory disciplines for the larger study. Rate of
completion and positive responses to the Montefiore social needs screener will support its use in the
TOC process, and any successful linkage to social services or community resources will show feasibility
of this approach to impact on those needs. Exploratory outcomes will give insight into sustainability of
intervention at 30 days post-discharge which will inform a longitudinal program component of the future
larger intervention.
The study team and study advisor...

## Key facts

- **NIH application ID:** 10869841
- **Project number:** 1R03HS029977-01
- **Recipient organization:** ALBERT EINSTEIN COLLEGE OF MEDICINE
- **Principal Investigator:** Katherine E Di Palo
- **Activity code:** R03 (R01, R21, SBIR, etc.)
- **Funding institute:** AHRQ
- **Fiscal year:** 2024
- **Award amount:** $100,000
- **Award type:** 1
- **Project period:** 2024-05-01 → 2026-04-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10869841

## Citation

> US National Institutes of Health, RePORTER application 10869841, Transitions of care program to make guideline-based recommendations actionable for patients with diabetic kidney disease (TOGA-DKD) (1R03HS029977-01). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/10869841. Licensed CC0.

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