In 2020, Portland, Maine nephrologist Paul Parker, MD, was getting ready to retire as a medical director of Fresenius Medical Care.
“I had already reduced my hospital visits and the number of patients I cared for in my practice,” Parker told Nephrology News & Issues. “I had 2 months to go.”
Something made the 72-year-old, long-time advocate for home dialysis change his mind: a transitional care unit (TCU).
When Fresenius completed construction of the Freedom Center in April 2020, Parker decided to stay as medical director.
“I was intent on making this successful,” he said.
TCUs have been around for more than 40 years in various forms, according to Brendan Bowman, MD, an associate professor of medicine at the University of Virginia (UVA) Medical Center who recently served as the medical director of 11 freestanding clinics for UVA. He worked with now-retired nephrologist Robert Lockridge, MD, and former UVA Health dialysis administrator Debbie Cote, MSN, RN, CNN, NE-BC, to establish the health system’s first TCU in 2017.
“Approximately 30% of patients who end up on dialysis get no early education on options,” Bowman told Nephrology News & Issues. “Everyone comes to dialysis with different levels of preparation. The TCU is an opportunity to educate patients, support them and get everyone on a level playing field.”
TCUs offer education to patients recently diagnosed with kidney failure who are undecided about a modality choice, providing information on in-center, home dialysis and transplantation. Most programs are four weeks, Parker said, but sometimes they can extend to 6 or 8 weeks depending on the medical needs of the patient, such as vascular access placement.
TCUs can provide education to patients already on dialysis who are interested in other options. Patients who need respite care – giving their at-home partners a break from assisting with dialysis – can also be accommodated, Parker said.
“We do not want to exclude any patients who are interested in other modality options. We are not trying to coerce someone into one modality choice or another. That would be a terrible mistake. The intent is to get them on the modality that is best for them,” Parker said.
The Freedom Center in Portland is a stand-alone facility, devoid of any outpatient dialysis stations. Many TCUs are attached to an in-center dialysis clinic or built inside an existing dialysis facility, however.
Having a stand-alone clinic like the Freedom Center helps to keep the educational effort unbiased, Parker said. “Sometimes, we do have patients come to the center and tell us they want to start on peritoneal dialysis,” Parker said. “That’s fine; we can accommodate them.”
Bowman, now a vice president for medical affairs at DaVita Kidney Care, agrees that TCUs need to present all modalities equally. “It is important that you do not bias patients toward home [therapy], but it is important that you give home equal footing with all other modalities options,” Bowman said. “If you do a good job of educating them and they make an informed choice, they often choose home if they feel it is a safe choice for them.”
Fresenius Kidney Care has built more than 100 TCUs in the last 2 years. Dinesh Chatoth, MD, associate chief medical officer, said on a recent company podcast.
“ ... [T]ransitional care refers to coordination and continuity of health care during passage from one care setting to another,” he said. “In simple terms, a good example of transitional care would be coordination of care when a patient moves from a hospital setting to a skilled nursing facility. This concept has been applied also in patients with chronic illness, like chronic kidney disease, where our patients have complex care needs at different stages of the illness.
“Every patient who is new to dialysis or transitioning between renal replacement therapies, including failed PD or transplant, should begin their experience in a transitional care unit,” Chatoth said.
TCUs like the Freedom Center offer emotional and psychological support for patients who are unprepared for kidney failure.
“A patient is not ready to accept any education until they feel emotionally and psychologically supported,” Chatoth said. “So the first thing we do is support them, and then they are ready to receive the education. And then the focus shifts toward providing modular education on dialysis options, including PD and home hemodialysis.”
Other subjects covered in TCUs operated by Fresenius include transplantation, vascular access and cannulation, nutrition, fluid management, the dialysis prescription and medications.
“It is a comprehensive education plan,” Chatoth said. “While the goals of a TCU are for more patients to choose home dialysis, it is important to recognize that if a patient chooses in-center dialysis, we believe that those patients will have better clinical outcomes because of the education they received in a TCU,” Chatoth said.
Parker acknowledges that his advocacy for home dialysis – and the benefits he sees in that modality choice – influence the direction of his practice. “If you can drive a car, you can learn home hemodialysis. We want to make sure that patients who can benefit from home therapy have access to that option.”
When the Freedom Center opened in April 2020, Parker and his staff welcomed 56 patients to the 4-week program. By January 2021, that census grew to 99 patients. So far, 127 new patients have come through the TCU training program. Of that group, 44 patients started renal replacement therapy on PD and 32 on home hemodialysis, Parker said.
It has been difficult to gauge the success of TCUs, Bowman said, because many are single units operated by different dialysis providers. He estimates there are more than 400 TCUs in the United States and he is trying to start a registry.
“Primary outcomes tracked by dialysis providers tend to be short duration – typically, modality selection,” Bowman said. “Data are retrospective and subject to patient selection bias.
“We are lacking consistent long-term outcomes, like the effect of TCUs on mortality, hospitalizations and home failure rate.”
Cote, who managed the TCU at the UVA when it opened in 2017, said in a 2019 article published on Healio that improvement in outcomes included a significant decrease in dialysis-related hospitalizations and readmissions. Cote credited improvements to the educational component of the program, which begins in the first week and incorporates meetings with a dietitian, a social worker and a nurse in addition to a nephrologist.
“The first week is helping patients cope with the changes in their lifestyle and getting to know them,” Cote said. “It is an intense time for social work.”
Cote said patients can become overwhelmed in navigating medical and financial decisions, all while experiencing uremia, which increases feelings of mental confusion. A social worker at a TDC unit can reassure the patient and answer questions, she said.
Bowman and Parker said TCU patients undergo dialysis 4 days a week using NxStage SystemOne HHD machines. Cote said the use of a slower machine offered four times a week instead of three still allowed patients to benefit from gentler treatment.
“If patients feel the difference on the home machine and see us using them and they want to [choose] home hemo[dialysis], then they have already had some exposure,” Cote said.
Bowman cited results presented at the Canadian Society of Nephrology Annual Meeting in 2014 where Meirovich and colleagues showed that, among 180 new dialysis patients enrolled from 2011 to 2013 in a TCU, 56% of patients selected a home therapy vs. 21% in a non-TCU group.
Prior to opening the TCU at the UVA Medical Center in Charlottesville in 2017, Bowman said there was a 5% to 7% conversion of in-center patients to home therapy each year.
“After we opened the TCU, we started converting about 30% of new starts to home,” Bowman said. “About 60% to 65% of new starts on dialysis went through the program.”
From February 2017 to May 2019, 84 patients entered the UVA TCU program. Outcome metrics included overall hospitalizations, hospitalization for fluid overload, education in antihypertensive medication use, and time to referral for vascular access and for transplantation.
Results showed 66% of patients chose in-center dialysis, and 30% of patients transition to home therapies. Patients in the TCU program had no hospital admissions for volume overload.
But Bowman said it is important to define what a TCU is when reviewing outcomes.
“A TCU is not ‘the intervention,’” he said. “There is nothing special about calling some square footage a ‘TCU.’ It is the interventions performed within the program that drive the desired TCU outcomes. Interventions used in a TCU have a robust evidence base, providing enhanced emotional and educational support to patients when they initiate dialysis.”
Bowman said the renal community should consider research on other outcomes from TCUs, including whether these improve survival, reduce overall cost of care, increase timely access creation and whether these can reduce health care disparities.
“The key is that patients believe, after getting the modality education they need, that the modality they pick is the best suited for them,” Bowman said.
Parker sees a difference between traditional modality options education, which dialysis providers are required to offer to all Medicare patients, and the TCU.
“Someone might say, ‘You can do all of this in a traditional clinic setting – there is nothing magical here.’
But I do not believe that is true. The difference is these patients are being helped with an understanding of their modality options in a steady form of instruction. Each day, they learn something new,” Parker said.
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