Potential Benefits of Transitional Care Programs for the Initial Days of Dialysis

During the first 90 days of dialysis, kidney patients often experience fear, confusion and a heightened vulnerability to health challenges—such as unplanned dialysis initiation, access failures, inappropriate target weights and medications that need to be adjusted. Hospitalization rates, mortality rates and overall costs for unplanned starts, as a result, can be significantly higher during this time. These outcomes may, in part, be mitigated by modifying the approach to care during this vulnerable period of time. One way to better manage these first few weeks of dialysis is through designing transitional care programs (TCPs) for dialysis—programs that offer more-intense education and shared-decision making to help improve modality selection, offer more-focused assessments for risk stratification and provide individually focused dialysis prescriptions—to help make sure new patients are receiving the individualized care and resources they need during this time.

Key components of a transitional care program

While not a new concept, TCPs are gaining increased attention worldwide as programs that can ultimately help make a difference in outcomes and patient quality of life. In December 2016, a group of medical providers interested in improving patient outcomes formed the Transitional Care Demonstration Initiative Work Group to outline the model of an effective TCP. Often accounting for patients who crashed into dialysis and/or did not receive adequate education prior to their dialysis start, effective TCPs can include the following.

• Providing increased access to nurses and other members of the care team to help promote trusting relationships between the patient and the care team and answer any patient questions.
• Educating in depth on all modalities, including in-center hemodialysis, home hemodialysis, peritoneal dialysis and kidney transplantation. The patient should be informed that different modalities will likely be required at different times over the duration of care.
• Developing an individualized care plan based on each patient’s needs, goals and home environment. This effort requires shared-decision making between physician and patient.
• Offering patients self-care training and hands-on experience with different dialysis modalities.
• Stabilizing patients, which sometimes requires providing more-frequent, gentler dialysis treatments during the first few days and adjusting medications, target weights and diets as needed.

The ultimate goals of a TCP program include helping reduce complication rates, preserve residual renal function if possible, increase the number of patients on the modality that is best-suited for them, ensure patients are given an individualized care plan and increase kidney transplantation rates.

Transitional care programs around the world

In the United Kingdom, Canada and the United States, transitional dialysis—and components of transitional dialysis—have started to emerge with promising results, including the following.

• The United Kingdom developed the Shared Haemodialysis Care model, in which the care team helps patients become more involved with their own treatments. As active participants in their care, patients learn how to take their blood pressure, program their own machine and perform other dialysis functions.
• Grand River Hospital (in Ontario, Canada) launched the Right Start Unit for incident dialysis patients in 2009. In the unit, patients in the unit (typically those who crash into dialysis) are comprehensively educated on kidney disease and dialysis and are often able to receive dialysis at home. Patients in a study group experienced a 22 percent greater reduction in mortality risk and an 8 percent reduction in hospital readmissions than a matched cohort.
• Renal Ventures Management developed the Coaching for Actions, Results and Empowerment program (RVCARE), which focuses on education, better access, volume management, nutritional status and transitioning patients to the dialysis modality of their choice within the first 120 days of dialysis. There was a four-fold increase in peritoneal dialysis therapy uptake than reported averages and dramatic reductions in mortality.

Challenges with launching transitional care programs

Many experts agree that TCPs are a crucial part of helping improve patients’ transitions to dialysis, yet multiple challenges still exist in developing and launching these programs, including the following.

• Determining where these programs will be located and how they will work operationally. This includes determining the necessary increase in staff and required skill sets and whether the program will be provided in the patient home, a home dialysis program, at an in-center location (separate from the main dialysis floor) or in an entirely separate transitional dialysis
• Projecting costs. Labor costs, potential increased individualized dialysis days and maintaining separate locations will increase costs, but the extent has not yet been determined.
• Partnering with nephrologists. TCPs require not only more of a physician’s time but also a commitment to shared-decision making and more practice collaboration (if regional magnet care approaches were to develop rather than multiple TCPs).
• Evaluating at-risk patients. Identifying at-risk patients, indexing their level of acuity and fragility, accounting for their comorbidity load and targeting modalities to address risk is critical to helping decrease mortality rates and hospitalization days.
• Securing support from the Centers for Medicare & Medicaid Services (CMS). TCP results and data need to be provided to CMS and state surveyors to garner their support moving forward. Efforts could include piloting a small number of differing TCP delivery sites to better understand the model(s) that will help drive the greatest advancement in patient experience, patient outcomes and cost for care delivered during the first few weeks of dialysis.

While these challenges may be formidable, undertaking a thorough evaluation of TCPs through well-designed pilots (with input from both state and CMS) should provide the necessary data that are critical to improving the clinical care pathway for new dialysis patients.