Innovations to Increase Home Hemodialysis Utilization: The Transitional Care Unit

Abstract

A large proportion of patients undergoing incident dialysis start in-center hemodialysis with suboptimal preparation and predialysis education. Transitional care units deliver a structured program by dedicated staff, with less patient-to-staff ratios than in regular in-center dialysis care, with the goals of supporting the emotional and physical well-being of patients while providing them with education and equipping them with the right tools to start their journey on dialysis. Key components of these programs include an emphasis on patient activation and self-management, educating and supporting patients to make informed modality choices, timely coordination of care, and an integrated approach to formation and use of the dialysis access. While data are still limited on best practices and on outcomes of these programs at a large scale, endorsing the model of transitional care units is a step in the right direction to fill the gap in our current care system. A large proportion of patients undergoing incident dialysis start in-center hemodialysis with suboptimal preparation and predialysis education. Transitional care units deliver a structured program by dedicated staff, with less patient-to-staff ratios than in regular in-center dialysis care, with the goals of supporting the emotional and physical well-being of patients while providing them with education and equipping them with the right tools to start their journey on dialysis. Key components of these programs include an emphasis on patient activation and self-management, educating and supporting patients to make informed modality choices, timely coordination of care, and an integrated approach to formation and use of the dialysis access. While data are still limited on best practices and on outcomes of these programs at a large scale, endorsing the model of transitional care units is a step in the right direction to fill the gap in our current care system. Clinical Summary•Patients start in-center hemodialysis unprepared and with suboptimal involvement in the choice of dialysis modality. The current model of in-center hemodialysis care does not cater to the needs of those commencing dialysis.•Despite that transition to home dialysis may result in better patient experience and outcomes, most patients accept in-center dialysis as their new reality.•Transitional care units offer an opportunity to prepare patients commencing in-center hemodialysis with the right tools to embark on their new life on dialysis by having more involvement in their own care, including an informed modality choice. This may be especially important for those patients who did not receive predialysis modality education.•The transitional care unit model continues to evolve, and we continue to get more data on outcomes. We need to pay attention to several key elements of the model, including patient education and activation and care coordination. This new model will ultimately allow more patients to experience the many benefits of home dialysis. •Patients start in-center hemodialysis unprepared and with suboptimal involvement in the choice of dialysis modality. The current model of in-center hemodialysis care does not cater to the needs of those commencing dialysis.•Despite that transition to home dialysis may result in better patient experience and outcomes, most patients accept in-center dialysis as their new reality.•Transitional care units offer an opportunity to prepare patients commencing in-center hemodialysis with the right tools to embark on their new life on dialysis by having more involvement in their own care, including an informed modality choice. This may be especially important for those patients who did not receive predialysis modality education.•The transitional care unit model continues to evolve, and we continue to get more data on outcomes. We need to pay attention to several key elements of the model, including patient education and activation and care coordination. This new model will ultimately allow more patients to experience the many benefits of home dialysis. More than half a million people in the United States rely on dialysis to sustain their lives.1United States Renal Data System2020 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2020Google Scholar Dialysis, however, should not just save lives but also enable people to live with the least symptoms, while receiving a treatment that minimizes interference with life activities and reduces damage to other organs.2Tong A. Palmer S. Manns B. et al.The beliefs and expectations of patients and caregivers about home haemodialysis: an interview study.BMJ Open. 2013; 3Google Scholar,3Evangelidis N. Tong A. Manns B. et al.Developing a set of core outcomes for Trials in hemodialysis: an international Delphi survey.Am J Kidney Dis. 2017; 70: 464-475Google Scholar While in-center hemodialysis (HD) answers the first need, it does not come close to answering the others. On the other hand, home dialysis can offer better physical well-being, more flexibility, liberalization of fluid and diet, less fatigue, better quality of life, and better maintenance of cardiac health.4Budhram B. Sinclair A. Komenda P. Severn M. Sood M.M. A comparison of patient-reported outcome measures of quality of life by dialysis modality in the treatment of kidney failure: a systematic review.Can J kidney Health Dis. 2020; 7 (2054358120957431)Google Scholar,5Ibrahim A. Chan C.T. Managing kidney failure with home hemodialysis.Clin J Am Soc Nephrol. 2019; 14: 1268-1273Google Scholar Despite these advantages, less than 2% of patients are on home hemodialysis (HHD).1United States Renal Data System2020 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2020Google Scholar Among the causes of this lag of uptake of HHD are inadequate awareness and education of patients and clinicians, suboptimal systems that address patients’ psychosocial issues, and challenges related to vascular access preparation and use.6Salim S.A. Zsom L. Cheungpasitporn W. Fülöp T. Benefits, challenges, and opportunities using home hemodialysis with a focus on Mississippi, a rural southern state.Semin Dial. 2019; 32: 80-84Google Scholar We need to increase the focus on these issues to enable more patients to take advantage of the many benefits of HHD. The recent Advancing American Kidney Health executive order calls for an increase in the uptake of home dialysis and sets a goal of the US Centers for Medicare & Medicaid Services to have 80% of incident patients with kidney failure begin care with pre-emptive kidney transplantation or home dialysis therapy by 2025.7Executive Order on Advancing American Kidney Health. The White House.https://www.whitehouse.gov/presidential-actions/executive-order-advancing-american-kidney-health/Date: 2019Date accessed: December 31, 2020Google Scholar This ambitious goal calls for us to address the gaps in our current system and look for disruptive innovations in the way we provide dialysis care in our drive toward more value-based health care. A process of improving education about home dialysis and increasing easy access to home modalities has been known for some time as one of the main pillars to advance home therapies. In many ways, this has improved over time, as evident by more than doubling of the number of patients performing home dialysis between 2008 and 2018, reaching a home dialysis utilization of 12.5%.1United States Renal Data System2020 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2020Google Scholar Despite the improvement, there is a lot of opportunities for more growth in the percentage of patients using home dialysis. Moreover, only 15% of patients on home dialysis are on home HD, a percentage that remained stable over at least the last decade.1United States Renal Data System2020 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2020Google Scholar Given the many benefits of home HD, these observations call for an integrated approach to identify and address the reasons behind the limited uptake of home HD. There is still a substantial number of patients who end up at the start of dialysis in an in-center HD setting with limited or no education about home dialysis. This reality represents an opportunity we should not miss. Patients being prescribed thrice weekly HD are offered a second chance to evaluate the option of home therapy or self-care in center. Both options have the potential to be significant life-changers for patients and their families. In this article, we discuss the role that transitional care unit (TCU) play in bridging the gap in the current care delivery system to enable patients to recognize the benefits and suitability of home HD and support their transition to their modality of choice. Information Box 1 summarizes the main elements in positioning TCUs to achieve this goal.Information Box 1Main factors in standard care vs transitional care units influencing modality choiceTabled 1Standard Care for Incident In-Center HD Patients•Suboptimal predialysis education•Fear and anxiety•Education by multiple rushed care team members•Environment conducive of perception of complicated treatment►•Overwhelmed•Acquire false beliefs•Relinquish control•Accustomed to in-center HD care►•Most patients remain on in-center HD as a default optionTransitional Care Unit for Incident HD Patients•Addressing physical and psychosocial well-being firstoDedicated staff with more timeoGetting to know the patient and family well•Patient activationoTailored education to patient's needs, pace, and style of learningoPatient involvement in their own dialysis treatment (learning by doing)oPeer mentoring and peer support groups•Coordination with other teamsoCoordination with the home program for early engagement, assessment, and lining up for trainingoVascular access formation and use•Home-like settings and separation from in-center HD normsoStaff with real experience in home dialysisoSeparate location of physical spaceoExposure to home dialysis machines►•Patients are empowered to make the right choice for themselves.•More patients are expected to choose and remain on home modalities. Open table in a new tab Tabled 1Standard Care for Incident In-Center HD Patients•Suboptimal predialysis education•Fear and anxiety•Education by multiple rushed care team members•Environment conducive of perception of complicated treatment►•Overwhelmed•Acquire false beliefs•Relinquish control•Accustomed to in-center HD care►•Most patients remain on in-center HD as a default optionTransitional Care Unit for Incident HD Patients•Addressing physical and psychosocial well-being firstoDedicated staff with more timeoGetting to know the patient and family well•Patient activationoTailored education to patient's needs, pace, and style of learningoPatient involvement in their own dialysis treatment (learning by doing)oPeer mentoring and peer support groups•Coordination with other teamsoCoordination with the home program for early engagement, assessment, and lining up for trainingoVascular access formation and use•Home-like settings and separation from in-center HD normsoStaff with real experience in home dialysisoSeparate location of physical spaceoExposure to home dialysis machines►•Patients are empowered to make the right choice for themselves.•More patients are expected to choose and remain on home modalities. Open table in a new tab With good predialysis education, 30-50% of patients choose home dialysis.8Liebman S.E. Bushinsky D.A. Dolan J.G. Veazie P. Differences between dialysis modality selection and initiation.Am J Kidney Dis. 2012; 59: 550-557Google Scholar However, a large proportion of patients have suboptimal or crash starts to dialysis.9Chiu K. Alam A. Iqbal S. Predictors of suboptimal and crash initiation of dialysis at two tertiary care centers.Hemodial Int. 2012; 16: S39-S46Google Scholar Even among patients with chronic kidney disease in nephrologist care, uncertainty about disease progression makes it hard to well-time the modality education.10Song M.K. Lin F.C. Gilet C.A. Arnold R.M. Bridgman J.C. Ward S.E. Patient perspectives on informed decision-making surrounding dialysis initiation.Nephrol Dial Transpl. 2013; 28: 2815-2823Google Scholar Furthermore, before dialysis, patients can be averse to full engagement with dialysis education.11Henry S.L. Munoz-Plaza C. Garcia Delgadillo J. Mihara N.K. Rutkowski M.P. Patient perspectives on the optimal start of renal replacement therapy.J Ren Care. 2017; 43: 143-155Google Scholar It is not surprising then that a high proportion of patients feel they were not involved in modality choice or are not satisfied with their pretreatment education.10Song M.K. Lin F.C. Gilet C.A. Arnold R.M. Bridgman J.C. Ward S.E. Patient perspectives on informed decision-making surrounding dialysis initiation.Nephrol Dial Transpl. 2013; 28: 2815-2823Google Scholar,12Fadem S.Z. Walker D.R. Abbott G. et al.Satisfaction with renal replacement therapy and education: the American Association of Kidney Patients survey.Clin J Am Soc Nephrol. 2011; 6: 605-612Google Scholar The early period after starting in-center dialysis is thus the next opportunity to re-engage the patient and renegotiate the proper modality choice. This, however, is hard to achieve in the current care delivery system. On one side, people commencing dialysis are anxious and fearful.13Griva K. Seow P.S. Seow T.Y. et al.Patient-related barriers to timely dialysis access preparation: a qualitative study of the perspectives of patients, family members, and health care providers.Kidney Med. 2020; 2: 29-41Google Scholar They are coming to a new chapter in their lives and are occupied by how this treatment will save their lives. They are overwhelmed by the number of team members taking care of them and by the advice they are getting. They are making many adjustments that they are worried will affect their lives and livelihood, as well as the lives of their loved ones. At the time, they are these large and complicated dialysis with staff to and On the other hand, in-center staff who provide the care and education are with large patient-to-staff With of patients may accept that they are to is new reality and the right and only and patients averse to K. Manns B. G. 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