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Innovations to Increase Home Hemodialysis Utilization: The Transitional Care Unit

      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.

      Key Words

      • 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.
      United States Renal Data System
      2020 USRDS Annual Data Report: Epidemiology of kidney disease in the United States.
      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.
      • Tong A.
      • Palmer S.
      • Manns B.
      • et al.
      The beliefs and expectations of patients and caregivers about home haemodialysis: an interview study.
      ,
      • Evangelidis N.
      • Tong A.
      • Manns B.
      • et al.
      Developing a set of core outcomes for Trials in hemodialysis: an international Delphi survey.
      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.
      • Budhram 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.
      ,
      • Ibrahim A.
      • Chan C.T.
      Managing kidney failure with home hemodialysis.
      Despite these advantages, less than 2% of patients are on home hemodialysis (HHD).
      United States Renal Data System
      2020 USRDS Annual Data Report: Epidemiology of kidney disease in the United States.
      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.
      • Salim S.A.
      • Zsom L.
      • Cheungpasitporn W.
      • Fülöp T.
      Benefits, challenges, and opportunities using home hemodialysis with a focus on Mississippi, a rural southern state.
      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.
      Executive Order on Advancing American Kidney Health. The White House.
      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%.
      United States Renal Data System
      2020 USRDS Annual Data Report: Epidemiology of kidney disease in the United States.
      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.
      United States Renal Data System
      2020 USRDS Annual Data Report: Epidemiology of kidney disease in the United States.
      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.
      Main factors in standard care vs transitional care units influencing modality choice
      Tabled 1
      Standard 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 option
      Transitional Care Unit for Incident HD Patients
      • Addressing physical and psychosocial well-being first
        • o
          Dedicated staff with more time
        • o
          Getting to know the patient and family well
      • Patient activation
        • o
          Tailored education to patient's needs, pace, and style of learning
        • o
          Patient involvement in their own dialysis treatment (learning by doing)
        • o
          Peer mentoring and peer support groups
      • Coordination with other teams
        • o
          Coordination with the home program for early engagement, assessment, and lining up for training
        • o
          Vascular access formation and use
      • Home-like settings and separation from in-center HD norms
        • o
          Staff with real experience in home dialysis
        • o
          Separate location of physical space
        • o
          Exposure 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.

       The Gap in the Current Care System

      With good predialysis education, 30-50% of patients choose home dialysis.
      • Liebman S.E.
      • Bushinsky D.A.
      • Dolan J.G.
      • Veazie P.
      Differences between dialysis modality selection and initiation.
      However, a large proportion of patients have suboptimal or crash starts to dialysis.
      • Chiu K.
      • Alam A.
      • Iqbal S.
      Predictors of suboptimal and crash initiation of dialysis at two tertiary care centers.
      Even among patients with chronic kidney disease in nephrologist care, uncertainty about disease progression makes it hard to well-time the modality education.
      • Song 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.
      Furthermore, before dialysis, patients can be averse to full engagement with dialysis education.
      • Henry S.L.
      • Munoz-Plaza C.
      • Garcia Delgadillo J.
      • Mihara N.K.
      • Rutkowski M.P.
      Patient perspectives on the optimal start of renal replacement therapy.
      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.
      • Song 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.
      ,
      • Fadem S.Z.
      • Walker D.R.
      • Abbott G.
      • et al.
      Satisfaction with renal replacement therapy and education: the American Association of Kidney Patients survey.
      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.
      • Griva 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.
      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 same time, they are seeing these large and complicated dialysis machines, with staff humming around responding to frequent alarms and complications. On the other hand, in-center staff who provide the care and education are very burdened with large patient-to-staff ratios. With all of that, patients may accept that what they are exposed to is new reality and the right and only solution. “Learned helplessness” ensues, and patients become averse to self-care.
      • McLaughlin K.
      • Manns B.
      • Mortis G.
      • Hons R.
      • Taub K.
      Why patients with ESRD do not select self-care dialysis as a treatment option.
      It is no wonder then that the rate of transfer to home dialysis tapers down significantly after the first few weeks on in-center HD; for instance, one study showed that the probability of switching to peritoneal dialysis drops from 7.0% at month 1 to 0.9% at month 4 of dialysis.
      • Lin E.
      • Chertow G.M.
      • Bhattacharya J.
      • Lakdawalla D.
      Early delays in Insurance Coverage and Long-term Use of home-based peritoneal dialysis.
      Patients commencing dialysis are vulnerable and need more attention and support. To disrupt the status-quo, a system dedicated to care of patients commencing in-center HD is required. Dedicated care programs at the time of this transition include a variety of bundled interventions, particularly patient education and case management, leading to optimized decision-making and improved outcomes.
      • Attalla M.
      • Friedman Z.
      • McKeown S.
      • et al.
      Characteristics and Effectiveness of dedicated care programs for patients starting dialysis: a systematic review.
      Multiple previous articles elaborated more on the purpose, structure, and function of these programs.
      • Bowman B.
      • Zheng S.
      • Yang A.
      • et al.
      Improving incident ESRD care via a transitional care Unit.
      • Morfin J.A.
      • Yang A.
      • Wang E.
      • Schiller B.
      Transitional dialysis care units: a new approach to increase home dialysis modality uptake and patient outcomes.
      • Lockridge R.
      • Weinhandl E.
      • Kraus M.
      • et al.
      A systematic approach to Promoting home hemodialysis during end stage kidney disease.

       TCUs—an Overview

      A TCU is a program that cares for patients commencing in-center HD. A TCU typically provides dedicated staff with more time for the patient in a structured program that is delivered typically over 3 to 8 weeks. The time made available to the patient allows the health care team to really learn about the individual patient and tailor their education and support. The program is structured to first address the patient's fears and anxieties, to get to know the patient well, and get the patient to know the care team. The initial period also focuses on stabilizing the patient physically. These two elements are important because a patient who is unwell emotionally or physically cannot engage well in learning and decision-making.
      • Morton R.L.
      • Tong A.
      • Howard K.
      • Snelling P.
      • Webster A.C.
      The views of patients and carers in treatment decision making for chronic kidney disease: systematic review and thematic synthesis of qualitative studies.
      Subsequently, the health care team engages the patient with education on different aspects of living on dialysis, such as education about fluid, diet, and medicines. Modality education is at the core of the curriculum, including education about immediate options (in-center or home HD and peritoneal dialysis) and about kidney transplant, or even, as appropriate, about not wanting to do dialysis.
      • Saeed F.
      • Ladwig S.A.
      • Epstein R.M.
      • Monk R.D.
      • Duberstein P.R.
      Dialysis Regret: prevalence and Correlates.
      The goal of modality education is not to make patients do home dialysis, but rather to enable the patient and family to make an informed choice through proper alignment of patient's goals and social conditions to the suitable modality. Inadvertently pushing patients to choose home dialysis when it is not the appropriate choice puts patients at high risk of failure and burdening the patient and family.
      • Jacquet S.
      • Trinh E.
      The potential burden of home dialysis on patients and caregivers: a Narrative review.
      The TCU then supports patients to pursue their modality choices.

       How TCUs Can Promote Transition to HHD

       Engaging the Patient and Family

      The TCU model is well-suited to deliver the shift in care delivery from a paternalistic prescribed care, which is inherent in in-center HD, to patient-driven care, which is more likely to involve self-care at home or in the center. Patient activation, which is brought about not only by improved knowledge but also by building skills and confidence,
      • Hibbard J.H.
      • Cunningham P.J.
      How engaged are consumers in their health and health care, and why does it matter?.
      allows the patient to take the driving seat. It is hard to deliver this type of care in a rushed setting. However, in TCUs, where there is more one-to-one care and more time allowed for the health care team, empowering the patient can become a reality. There is time for listening to the patient, acknowledging their wishes and way of thinking, transforming the education to answer the patient's immediate concerns, and work at the patient's pace. The team also engages the family and includes them in the discussions and teaching, which is key to successful follow through of plans. If family members are against these plans, with or without proper understanding, they will be bound to fail. In addition, family members can shed light on realities the patient is not accounting for. Voicing concerns and objections early in the process enables dealing with them at an early stage to avoid surprises and frustrations down the road.
      • Liebman S.E.
      • Bushinsky D.A.
      • Dolan J.G.
      • Veazie P.
      Differences between dialysis modality selection and initiation.

       Education Material

      Learning is about transfer of the experience and changing behavior. For that to happen, TCU staff need to account for the different learning styles: visual, aural, reading-writing, and kinesthetic.
      • Auguste B.L.
      • Girsberger M.
      • Kennedy C.
      • et al.
      Are adverse events in newly trained home dialysis patients related to learning styles? A single-centre retrospective study from Toronto, Canada.
      Different formats for educational materials, including the text, diagrams, audio, and videos, should be readily available. The variability also gives the coaches a repository of different flavors they can reach to, to vary their approach as necessary. The TCU team should involve patients in their dialysis care by working with them to perform tasks they are willing to do. Learning by doing not only emphasizes the education but also gives patients confidence that they can acquire and perform skills necessary for self-care, resulting in increased activation, reduced anxiety, and increased number of patients performing self-care or moving to dialyze at home.
      • Wilkie M.
      • Barnes T.
      Shared hemodialysis care: increasing patient involvement in center-based dialysis.

       Peer Mentoring and Peer Support

      Most of the time, neither the nephrologist nor the professionals involved in the delivery of dialysis therapy can truly relate to the experience of patients undergoing the life-changing events of staring dialysis therapies. Medical advice by professionals comes from a place of authority and knowledge. An essential complimentary component thus is peer support, in which patients hear and discuss the personal experiences of fellow patients who passed through the same experience. Besides the knowledge, peer-mentoring and peer support provide patients with acknowledgments, validation, trust, and confidence and can help patients make decisions by reflecting on real experiences.
      • Bennett P.N.
      • St Clair Russell J.
      • Atwal J.
      • Brown L.
      • Schiller B.
      Patient-to-patient peer mentor support in dialysis: improving the patient experience.
      TCUs should facilitate the several forms of peer support including support group meetings, individual face-to-face or telephonic meetings, and web-based support groups. A program that helps develop peer mentors through a dedicated peer mentoring education and support program can maximize their input in a TCU.
      • Bennett P.N.
      • St Clair Russell J.
      • Atwal J.
      • Brown L.
      • Schiller B.
      Patient-to-patient peer mentor support in dialysis: improving the patient experience.

       Integration with the Home Program

      Strong collaboration and coordination with the home dialysis program is crucial to the success of transitioning patients to the modality of choice. Early involvement of the home program helps at three levels: (1) supporting an informed modality choice: by connecting with the patient and family for education and to answer questions, (2) early evaluation for the patient's home and social conditions to prepare the patient and environment for successful delivery of dialysis at home, and (3) supporting access preparation and lining up the patient for training.
      TCU teams have to be versatile on home dialysis. It is not enough if they only receive education on home dialysis but they should also be familiarized with the TCU training materials. Having TCU staff who are only experienced in delivery of in-center HD risks propagation of misinformation about home therapies. In-center HD staff exposure to home dialysis is mainly through managing patients with poor experiences, such as experiences of those who transfer to in-center HD after complications. In-center HD staff also know dialysis as the complicated therapy, which is associated with frequent complications and is better delivered by experts. This leads to in-center staff having knowledge gaps regarding home therapies and as such may convey misperceptions regarding these modalities.
      • Firanek C.A.
      • Garza S.
      • Gellens M.E.
      • et al.
      Contrasting perceptions of home dialysis therapies among in-center and home dialysis staff.
      This problem extends beyond in-center HD staff and includes physicians. Physicians in fellowship training express low confidence in management of home HD, and part of the problem limiting the exposure to home therapies, particularly home HD, is the low prevalence of the modality itself.
      • Gupta N.
      • Taber-Hight E.B.
      • Miller B.W.
      Perceptions of home dialysis training and experience among US Nephrology fellows.
      TCU programs need to tightly collaborate with home programs to build their staff to become home dialysis experts. They need to know the success stories, the satisfaction of patients on home dialysis, the challenges and solutions, and the rate, causes, and outcomes of potential complications. They need to be aware of common myths about home dialysis and know how to address them. This in-depth level of knowledge and experience will increase their passion about home dialysis, resulting in a fair representation of home options to patients.

       Vascular Access Creation and Use

      In addition to that education about dialysis access, including avoidance of central venous catheters (CVCs), is part of the curriculum, dialysis access readiness can become a bottleneck toward successful transition to home dialysis training. In relation to home HD specifically, few key aspects related to dialysis access merit further discussion: (1) surgical formation of permanent access, i.e., arteriovenous fistula or graft (AVF or AVG), (2) the initial use of the permanent vascular access, (3) dealing with patient concerns such as needle phobia and fears of needle dislodgement, and (4) considerations for CVC use for home HD.
      The TCU team needs to establish good relations with the surgical team placing permanent access through the center medical director and the referring nephrologist. Rapid referral, assessment, and surgical placement of permanent access should take place once a decision is clear whether the patient will be going for peritoneal dialysis or HD. Early surgery enables access to the in-center HD staff with good experience in accessing new AVF. Otherwise, coordination between the in-center and home dialysis teams is needed for challenging new AVF. Other options include the use of ultrasound or marking the tract of the AVF.
      • Schoch M.
      • Bennett P.N.
      • Currey J.
      • Hutchinson A.M.
      Point-of-care ultrasound use for vascular access assessment and cannulation in hemodialysis: a scoping review.
      • Gardezi A.I.
      • Sequeira A.
      • Narayan R.
      Going home: access for home modalities.
      • Ward F.L.
      • Faratro R.
      • McQuillan R.F.
      Self-cannulation of the vascular access in home hemodialysis: Overcoming patient-level barriers.
      Needle phobia or needle fear is a major barrier for patients toward home HD.
      • McLaughlin K.
      • Manns B.
      • Mortis G.
      • Hons R.
      • Taub K.
      Why patients with ESRD do not select self-care dialysis as a treatment option.
      Peer support and observing other training patients place needles may help new patients. Other options available for the TCU team include strategies to reduce pain, such as warm compressions and topical analgesia, among other interventions.
      • Gardezi A.I.
      • Sequeira A.
      • Narayan R.
      Going home: access for home modalities.
      ,
      • Ward F.L.
      • Faratro R.
      • McQuillan R.F.
      Self-cannulation of the vascular access in home hemodialysis: Overcoming patient-level barriers.
      Education should highlight that the risk of needle dislodgement is low and should include information about prevention techniques.
      • Gardezi A.I.
      • Sequeira A.
      • Narayan R.
      Going home: access for home modalities.
      ,
      • Ward F.L.
      • Faratro R.
      • McQuillan R.F.
      Self-cannulation of the vascular access in home hemodialysis: Overcoming patient-level barriers.
      Finally, consideration need to be made in patients with CVCs who choose to do home HD, whether to wait until a permanent access is ready or transition immediately with CVC. While complication rates are lower in in-home HD patients with AVF or AVG than in those with CVC,
      • Rivara M.B.
      • Soohoo M.
      • Streja E.
      • et al.
      Association of vascular access type with Mortality, Hospitalization, and transfer to in-center hemodialysis in patients undergoing home hemodialysis.
      delaying transfer to home dialysis interferes with the chosen patient's lifestyle risks continued exposure to in-center HD complications and risks having the patient lose interest in transitioning to home HD. For these patients and those for whom a permanent vascular access might not possible, CVC use should not delay or prevent transitioning to home HD.
      • Ibrahim A.
      • Chan C.T.
      Managing kidney failure with home hemodialysis.

       Familiarity with Home Dialysis Machines

      A person's life goals should guide modality choice. However, their perceptions and misperceptions about the technology and how machines play a large role in modality choice requires consideration. On in-center HD, patient's first experience with dialysis machines is that they are large, complicated, and noisy. Patients' perceptions that the machine and supplies are going to medicalize their homes or make them look like hospitals is a barrier for transition to home dialysis.
      • Jacquet S.
      • Trinh E.
      The potential burden of home dialysis on patients and caregivers: a Narrative review.
      ,
      • Slon Roblero M.F.
      • Borman N.
      • Bajo Rubio M.A.
      Integrated care: enhancing transition from renal replacement therapy options to home haemodialysis.
      Several new products are now available for patients. TCU teams need to make patients aware of the many options available for them.
      • Agar J.W.
      • Perkins A.
      • Heaf J.G.
      Home hemodialysis: infrastructure, water, and machines in the home.
      • Plumb T.J.
      • Alvarez L.
      • Ross D.L.
      • et al.
      Safety and efficacy of the Tablo hemodialysis system for in-center and home hemodialysis.
      • Komenda P.V.J.
      • Harper G.
      • Wilson L.M.
      • Mitra S.
      • Breen C.
      • Milad J.E.
      Hemodialysis with the Quanta SC+: efficacy and Safety of a self-care hemodialysis machine.
      Patients will be able to have a machine with a small footprint, which has a friendly interface and is easy to operate. In addition, concerns about added cost (electricity, water, and plumbing) need to be addressed.
      • Jacquet S.
      • Trinh E.
      The potential burden of home dialysis on patients and caregivers: a Narrative review.
      New machines may use wireless technology to communicate with the health care team. Any concerns about Wi-Fi or cellular connectivity issues and related costs should be addressed. Mobile health technologies can be introduced early given that over two-third of all dialysis patients are mobile health proficient.
      • Hussein W.F.
      • Bennett P.N.
      • Pace S.
      • et al.
      The mobile health readiness of people receiving in-center hemodialysis and home dialysis.
      Early discussion regarding each patient's technological proficiency can aid in incorporating telehealth to support home dialysis transition. TCUs should expose the patients to home dialysis machines, not only by seeing them but also by working with the patient to picture them in their living rooms or bedrooms. Some TCU models use home HD machines during the transitional care period. Increased patient familiarity of home dialysis machines in this new environment helps overcome technology fear and anxiety.
      • Lockridge R.
      • Weinhandl E.
      • Kraus M.
      • et al.
      A systematic approach to Promoting home hemodialysis during end stage kidney disease.

       Preventing the In-Center HD Status from Becoming the Norm

      A key concern about the transitional period is having patients get accustomed to in-center dialysis. Change associated with starting dialysis is hard.
      • McLaughlin K.
      • Manns B.
      • Mortis G.
      • Hons R.
      • Taub K.
      Why patients with ESRD do not select self-care dialysis as a treatment option.
      It is even harder to make a transition more than once. If a patient adjusts to in-center HD, transitioning to another modality will involve a new facility, new staff, new learnings, and multiple other new life adjustments. For all modality options to have equal chance of being chosen, TCUs need to avoid making in-center HD seem like the default option for the patient. As much as possible, efforts need to be made to separate the TCU from in-center facilities in location, physical space, machines, and staff.

       How Promising Is a TCU Model in Relation to Growing of Home Dialysis?

      Dedicated staff with endorsement of an enthusiastic physician hold the key to successful programs. It is still not clear how successful these programs will be at a larger scale. In addition, it is not clear if patients embracing home HD as an initial therapy are going to persist with it, as they need to take on more work but have not experienced the burdens and adverse events of in-center HD. In fact, the data show that home HD patients in the United States and other countries currently are mostly prevalent patients while peritoneal dialysis is the home modality choice of incident patients. The role of TCUs affecting this distribution will need to be seen and would benefit from partnering with large patient-focused organizations such as the Patient-Centered research Outcomes Institute. The fact that home HD was the only solution for uremia in the past indicates that it certainly is a valid option. While nephrologists and other professionals see the advantages of home HD, both from experience and from the published data, the questions is whether patients value being in charge of their own care while taking on more responsibility early in their journey with dialysis care.

      Conclusion

      In summary, the underutilization of HHD in the United States can be increased through the incorporation of TCU programs in future models of care. Presently, there are limited data to support one definitive TCU model or to indicate how much growth we would anticipate as a result of TCU program implementation. It appears reasonable to hypothesize that focusing on more intense clinical stabilization with patients being equipped with self-management and coping mechanisms would benefit patients to choose home HD more often. The sharing of experience by the United States and international dialysis providers can contribute to improvement of TCUs and potentially increased home HD utilization.

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