The nephro-geriatric unit in a lean-oriented in-hospital model of care.

Nephrologists worldwide are gradually coping with elderly patients. This is because of the burden of chronic disease in the aging population and specifically chronic kidney disease (CKD). CKD in the elderly rarely occurs in isolation from other chronic conditions and can often be a marker of these conditions themselves. Geriatricians usually take care of chronic conditions and are trained to perform comprehensive geriatric assessment, a tool to estimate frailty, that is the risk of adverse outcome, disability, and death in the clinical setting of elderly inpatients. Unfortunately, they are not used to a CHD invasive and non-invasive approach and so there is no doubt about the need for a co-managed care model for these patients. However, where and how this model must be realized is still questionable. New hospital care models are patient-centered and encompass the concepts of departments to embrace the differentiated levels of care approach. According to this model the hospital is subdivided into three different standards of care: 1-high; 2 -intermediate; 3- low and this organization avoids inpatients being transferred frequently to different units, receiving specific care easily obtained by moving and changing the medical staff in charge of the patient. The lean care approach integrates the principles of the Toyota Producing System (TPS), a leading system of the industrial world, into intensity-based hospital care, thereby maximizing quality processes and promoting co-managed care as in the nephro-geriatric clinical setting.