1. Pre-survey: Before the implementation of the new model of follow-up, we performed a random sample survey among 50 patients. More than 90% patients agreed to build a platform for the communication between patient and patient, patient and medical staff.
2. The establishment of QQ group " Cleaning kidney in peritoneal dialysis patients ": The head nurse of the Renal Division will establish a QQ group and become the administrator. The head nurse will make working rules for QQ group follow- up. Medical staff will write down number of QQ group
and telephone in a card. Patients on peritoneal dialysis will be invited to join this group. If the patient cannot use the computer or is in serious condition, we will invite their relatives or nursing worker responsible for PD to join.
3. The follow-up management of QQ group:
1.PD technical guidance group: The director of the Renal Department and one attending physician will be in charge for guidance. And the doctors of the division will be the volunteer who will login in QQ group for the patients and solve questions once a week.
2.Follow- up management group: The head nurse and two specialized nurse will be responsible for making the training and follow-up plan. They will announce the follow- up information in a timely manner according to the follow-up plan, and organize activities related to health education in patients on peritoneal dialysis. If the patient is unable to participate in regular activities, the managers will timely upload the health education information, and communicate with the patient using the QQ video, dialogue, file upload etc.
3．Management groups of peritoneal dialysis patients：The PD patients will be divided into 5 groups. One patient who has been on dialysis for more than two years and knows standard operation well with fewer complications will be responsible for one group. There will be five groups in total. The five patients who are responsible for the management of groups will participate in organizing the education, experience sharing, communicating with medical staff, and demand feedback etc.
4．The establishment of PD health education materials in the file library of QQ group . Medical staff will upload and update the PD health education materials, write "Peritoneal Dialysis Guide" and answer more than 100 questions may occur in the process of peritoneal dialysis. CAPD patients can study themselves at any time.
5. Encourage peer education with the help of QQ group among peritoneal dialysis patients. In the QQ group, patients may exchange their experience, small skills for PD emergency incidents, peer counseling etc.
6 ． We will establish the record of the follow- up for peritoneal dialysis patients. We will record the follow- up status and promptly notify the patients to change transfer set tube, monitor liquid exchange technique and help to
observe complications etc.