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How Transitional Care Units Educate and Prepare Patients New to Dialysis
Patients starting dialysis enter a world of unfamiliar technology, terminology, and procedures. During this time, they need support, compassion, and instruction to understand end stage renal disease (ESRD) and the best ways to manage their own care. In answer to these needs, Fresenius Kidney Care introduced Transitional Care Units (TCUs) at strategically selected dialysis centers nationwide. Physicians can refer patients to a TCU when they need to start dialysis and do not have a planned start.
In the TCU, patients learn about all their therapy choices and get the resources and confidence to pursue a treatment that best fits their lifestyle — whether home dialysis, in-center hemodialysis (HD), or getting on a transplant waitlist. Because patients are more engaged in their care, they may achieve better outcomes and see improvements to their health and lifestyle. That means fewer hospital visits, which can help reduce the cost of care and the burden on healthcare systems.1,2
What Are Transitional Care Units?
TCUs are dedicated spaces in dialysis centers meant to give patients encouragement and education as they start dialysis treatments. They typically include four dialysis stations in a specific area of the center. Each station is equipped with the machines, staff, and supplies necessary for a thorough introduction to kidney replacement therapy options —in-center HD, home hemodialysis (HHD), peritoneal dialysis (PD), and kidney transplantation.
Over a three- to five-week period, patients are taught about dialysis, dialysis machines, cannulation, sterilization practices, dietary needs, medications, and more. As part of this personalized approach, clinicians, social workers, and dietitians demonstrate techniques, offer guidance, answer questions, and offer emotional and psychological support. If referred by their kidney doctor, patients can try more frequent hemodialysis for themselves, which provides a therapy experience similar to HHD.
When patients complete the TCU program, they can more confidently decide to learn PD or HHD from a home training nurse or stay with in-center hemodialysis (HD). Of patients who start in the TCU, Fresenius Kidney Care has seen between 40 and 50 percent choose a home modality.3
How Are Patients Selected for Transitional Care Units?
While there are no absolute criteria for TCU participation, the primary focus is on people recently diagnosed with ESRD who are new to dialysis. Often, these patients have had little to no modality education and may not be aware of their therapy options. These patients may also be anxious or fearful about starting dialysis and need to feel supported. Others who could benefit from the program include:
- In-center HD patients interested in or ready for home dialysis
- PD patients who need to change modalities due to ineffective therapy
- Patients returning to dialysis after a failed kidney transplant
Examples of individuals who may not be strong TCU candidates include permanent patients of long-term care facilities with no care partner, those in hospice care, and those with severe cognitive impairment or unstable living arrangements.4
What Kind of Education Do TCU Participants Receive?
The federal government is encouraging more widespread adoption of home dialysis, and studies point to better patient outcomes with PD and HHD compared to HD.1,2 However, many patients start dialysis with little to no knowledge of their therapy choices.4 The goal of a TCU is for participants to learn about treatment options and ESRD care, and exit the program with a clear path forward and the support they need to succeed.
Successful TCU programs require a dedicated, multidisciplinary team and a comprehensive, organized curriculum. TCU teams include nurses, technicians, dietitians, social workers, financial coordinators, nurse practitioners, physician assistants, and nephrologists. Collectively, this team is responsible for several areas of administration, care, and training. A thorough four-week program may consist of the following:4
- Week 1: Patients are welcomed and introduced to their TCU team. The team provides reassurance and stability, helping patients mentally prepare to learn about their dialysis options. They talk with the patient about goals, concerns, and fears. They administer hemodialysis and adjust the patient’s prescription and medications as needed.
- Week 2: Education begins on the importance of dialysis and desired outcomes. The option of home therapy treatment (PD and HHD) is discussed as well as the option for a transplant. Patients are educated on the importance of their access type and vaccinations. If necessary, hemodialysis prescription and medications are further adjusted.
- Week 3: Home therapies are explored further. Participants meet with patients who are already on HHD and PD, hear about the freedom and flexibility as well as the tips for adjusting to therapy, and learn about home dialysis equipment. With permission from their nephrologist, patients can start more frequent hemodialysis and experience the difference in more frequent treatments. The TCU team guides discussions and decisions about next steps and modality choices (PD, HHD, or IHD). Hemodialysis prescriptions and medications may be adjusted once more.
- Week 4: When patients feel comfortable with the education provided and have decided their next step, they graduate and begin the transition out of the TCU. In many cases, patients choose home dialysis and begin more formal training. Plans for vascular access and transplant evaluation appointments are confirmed if relevant, and advanced care planning is discussed.
Giving New Dialysis Patients the Support and Education They Need
It’s important for people starting dialysis to feel supported and learn all they can about ESRD, treatment options, and managing their own care. Transitional care can help accomplish these goals, so in 2020 we developed new TCUs at 125 dialysis centers across the country, increasing access significantly and helping more patients feel empowered.
The TCU setting provides patients with the information, instruction, and time they need to make confident, informed choices about dialysis modalities and other aspects of care. Most importantly, TCU programs help promote a smooth start to dialysis, care continuity, and better health and well-being for our patients.
- Michael Kraus and Dinesh Chatoth, “Benefits of Home Hemodialysis,” Fresenius Medical Care North America, published July 12, 2019, https://fmcna.com/insights/articles/benefits-home-hemodialysis/.
- “Top 5 Reasons Home Dialysis Is Ready to Take Off,” Fresenius Medical Care North America, published March 26, 2019, https://fmcna.com/insights/articles/home-dialysis-top-5-reasons/.
- “A Smoother Start into Dialysis: Q&A with Joe Turk on Transitional Care Units,” Fresenius Medical Care North America, published August 19, 2020, https://fmcna.com/insights/articles/joe-turk-transitional-care-units/.
- Robert Lockridge Jr., Eric Weinhandl, Michael Kraus, Martin Schreiber, Leslie Spry, Prayus Tailor, Michelle Carver, Joel Glickman, and Brent Miller. “A Systematic Approach to Promoting Home Hemodialysis during End Stage Kidney Disease.” Kidney360 1, no. 9 (2020): 993-1001. doi: 10.34067/KID.0003132020