Episode 10: How Transitional Care Units Empower Patients to Manage Their Care with Dr. Dinesh Chatoth, Associate Chief Medical Officer of Fresenius Kidney Care
Transitional Care Units help people recently diagnosed with kidney failure learn about the treatment options available to them including home dialysis. Dr. Dinesh Chatoth, Associate Chief Medical Officer of Fresenius Kidney Care, discusses the importance of comprehensive, hands-on education that is individualized for each patient, empowering them to manage their own care.



Brad Puffer: Welcome, everyone, to this episode of Field Notes. I'm Brad Puffer on the medical office communications team at Fresenius Medical Care North America and your host for this discussion today. Here, we interview the experts, researchers, physicians, and caregivers who bring experience, compassion, and insight into the work we do every day.

A new initiative underway at Fresenius Kidney Care is helping people recently diagnosed with kidney failure better transition into dialysis and become more empowered in managing their own care. It's also helping record numbers of patients decide that home dialysis is the best option for their needs. It begins with new patients spending several weeks in a transitional care unit or TCU with dedicated staff and support rather than the first stop being a traditional outpatient dialysis center.

Earlier this summer, Fresenius Kidney Care announced plans to have 100 transitional care units open by the end of this year. And now we can announce that number has already been surpassed. So how did this idea transitional care begin? And why is it getting extra attention now? What does a TCU look like? And how is it different? What do physicians, care teams, and patients need to know? Can TCUs accelerate the adoption of home dialysis throughout the country? And what can other health care providers learn from this effort?

Here now to discuss this initiative is Dr. Dinesh Chatoth, associate chief medical officer for Fresenius Kidney Care. Dr. Chatoth is a nephrologist who previously ran a large private practice and has long been a champion of home dialysis as the best option for patients with kidney failure, aside from a transplant. Dr. Chatoth, thank you for being here. Welcome to Field Notes.

Dr. Dinesh Chatoth: Thank you Brad. It's my pleasure to participate in the Field Notes.

Brad Puffer: Well, Dr. Chatoth, I thought we'd just start off in your own words and get a sense of what exactly do we mean when we say transitional care, not just for kidney disease but generally in health care?

Dr. Dinesh Chatoth: Well, Brad, in the broadest sense, transitional care refers to coordination and continuity of health care during passage from one care setting to another. In simple terms, a good example of transitional care would be coordination of care when a patient moves, say, 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.

Brad Puffer: So we talked about patients diagnosed with kidney failure, how was this concept of transitional care so important for them?

Dr. Dinesh Chatoth: So when patients develop kidney failure and end-stage kidney disease, they are likely to start dialysis with the central venous catheter. In fact, that accounts for about 80% of all patients, when they start dialysis, they begin with the central venous catheter. They have a high risk of hospitalization, high risk of mortality, and they utilize health care resources for the first year they're on dialysis in a significant way.

They're in need for emotional support. They need to cope with a diagnosis of renal failure. And they need education on options, and then be medically managed better. So a transitional care unit provides that emotional support, allows for coordination of care, as well as provides patient and family education and support.

Brad Puffer: So for those who may be most familiar with an outpatient dialysis center, what do we really mean when we're talking about a transitional care unit? What does one look like? How when you walk into a TCU you know it's different?

Dr. Dinesh Chatoth: That's a great question, Brad. A typical outpatient dialysis clinic would have about 10 or 20 dialysis stations with chairs and hemodialysis machines across a large treatment floor. A transitional care unit is typically a pod of say four or five chairs that is identified as a section of that outpatient dialysis treatment facility where care is provided a little differently.

So one would see home hemodialysis equipment like NxStage machines along with traditional in-center hemodialysis machines. The area is not partitioned off. It's not separated from the rest of the treatment floor. But that pod or a transitional care unit would have a dedicated or trained nurse and a patient care technician who would manage and support the patient while providing treatments.

Now, if you would walk into a transitional care unit, you would see some patients actually being educated by the social worker or a dietitian, or you would see a dummy tummy where they could learn about peritoneal dialysis catheters or PD. So the tools to support education would be visible to you if you go into a transitional care unit.

Brad Puffer: It seems like the education offered goes really far beyond dialysis and far more in-depth than what you would traditionally find in an outpatient center. Everything from vascular access, nutrition, medication adherence, correct?

Dr. Dinesh Chatoth: That's correct, Brad. The initial focus is on medical management and providing patients emotional and psychological support. So keep in mind a patient is not ready to accept any education until they feel emotionally and psychologically supported. So the first thing we do is really support them, and then they're ready to receive the education. And then the focus shifts towards providing modular education on dialysis options, including PD, home hemodialysis.

Education on transplant, education about vascular access and cannulation, how to eat right, how to restrict fluids, and what kind of dietary restrictions are important, and that's provided by the dietitian, and also important things like adhering to the dialysis prescription and medications. So it's a comprehensive education plan, and eventually when patients decide they want to do, say peritoneal dialysis, we even refer patients for a PD catheter placement as they complete their TCU experience.

Brad Puffer: And how long does this experience last? I assume they're not there forever.

Dr. Dinesh Chatoth: So the patients in a transitional care unit are there for about four to five weeks. Now, when you look at the literatures, some of the transitional care units will have patients for up to eight weeks. But it is a short period of time. In our experience at Fresenius, we have patients for about four to five weeks, and we have a structured educational curriculum that we follow just to make sure that the patients get every aspect of the education they deserve while they're in the transitional care unit.

Brad Puffer: And at the end of the day, Dr. Chatoth, what is the ultimate goal when you look at a patient who goes through transitional care unit? What does success look like?

Dr. Dinesh Chatoth: Every patient who's new to dialysis or transitioning between renal replacement therapies, including failed PD or transplant, should begin their experience in a transitional care unit. So one of the first things we wanted as the goal, this is not for certain select patients but for every patient. The next important goal for TCU is that the patient should be, one, emotionally ready and coping well with the diagnosis of end-stage renal disease. That's such an important part how they receive the education and how well they do clinically on dialysis.

The other goal of TCU is to make sure the patients are medically well-managed and clinically stable, so their dialysis prescription, so that they feel good and are able to receive the education. And then the other important part of the TCU is that informed decision-making, so the patients can decide on all modalities as well as transplant. And then last but not the least, identify a support system so that the patients when they go home or stay in-center, they have families, friends, and other support groups who can support a patient.

While the goals of a TCU is for more patients to choose home dialysis, and that's definitely one of our goals, it's 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. So they would probably have timely placement of permanent vascular access, they would have better adherence to medication treatments, and they would be referred earlier for transplant.

So we are actually actively studying this population of patients who've been to a TCU and choose in-center to have a better understanding of how their clinical goals have improved after being in a TCU.

Brad Puffer: Well, you also brought up home dialysis which is one of the goals of establishing these TCUs. How do you believe that TCUs can help more patients make that choice? I have long heard you advocate that every patient should be offered home dialysis barring a few exceptions. We should first assume patients can do this, correct?

Dr. Dinesh Chatoth: Absolutely. I mean, most patients when they first are told they have kidney failure and need dialysis, they assume that dialysis is extremely complicated and is technically challenging. So the general belief is that it's the best for them to receive dialysis in a clinic under the care of a trained and experienced staff.

So when the patient is then emotionally stable, understand what their goals and values are, they feel better clinically and medically, and then they are educated so they can make an informed decision, they tend to choose home dialysis because now they feel empowered and they understand that they can do it at home.

So clearly, the TCU allows that environment where they can feel better, be educated better, and actually use dialysis machines, a home dialysis equipment, so that they actually feel like that equipment make me feel better so I can do this at home. That empowerment is really what drives people to want to do home dialysis.

Now, one thing that comes in the way of this are biases that nephrologists and clinicians have. We tend to size up patients and think we know what's best for our patients. When I was in clinical practice, I've been surprised many times, and have had patients who I thought were not so good candidates for home dialysis and actually do really well and thrive well on home dialysis. So I've been fooled myself.

And so I'm a believer that every patient should actually go to a TCU, be educated, and then make the decision. And I believe more patients will choose, especially when the nephrologist and the clinician biases don't come in the way.

Brad Puffer: Well, do you have any stories of a patient where these TCU experiences already made a difference, especially as it relates to someone who may have been apprehensive about their ability to do home dialysis?

Dr. Dinesh Chatoth: So Brad, I had a recent conversation with the nephrologist from the East Coast, and he has a very successful transitional care unit. And he shared a very interesting story with me about a middle-aged gentleman who actually presented to a local hospital there with severely uncontrolled blood pressure. And he was told by the nephrologist in the hospital that he had end-stage kidney failure. The patient's mother was on dialysis then passed away a few years prior. And so the patient who was employed, was living alone, and was divorced was presented with the option to do home dialysis, especially PD.

The physician I talked the patient in the hospital and thought the patient was a good candidate for PD. But again, the patient felt that he really was not a candidate for home dialysis and thought that outpatient dialysis was the best option for him. And honestly, the patient was emotionally distraught with a diagnosis of end-stage kidney disease and resigned to his fate, especially given that he had seen his mother go through in-center dialysis.

Now, what the physician did was to convince the patient to go to a transitional care unit without predetermining whether the patient is going to go home or in-center. He said, you go to a TCU and experience it, be educated and decide what's best for you. And what the physician told me is that the patient chose peritoneal dialysis after completing five weeks of TCU.

So I think what happened here is that the patient was stabilized, emotionally ready, and educated, and he realized that, hey, I can do this. And he was empowered to make that decision. And so the real best part of this story, one, he's doing well on PD and he continues to work. And so he's got his life back in a big way. So I think in a way, TCU has really helped some of these patients who otherwise would have not gone to home dialysis choose home therapies.

Brad Puffer: Well, that's great to hear, Dr. Chatoth. I'm sure there's many more stories out there just like that one. This clearly can have benefits to our patients. I understand it can really also benefit the care team, almost as much, is that right?

Dr. Dinesh Chatoth: Yes. I mean, so physicians and the care team members have been very welcoming to the TCU concept. It is always challenging for a physician to educate patients about complicated things like modalities in your office or in a hospital setting where you have 15, 20 minutes to go over options. So from a physician standpoint, to have the luxury of having a transitional care unit, where you would send your patients to, allows for the patients to be settled and be educated at a pace where they can understand what's been told. So physicians are really in favor of transitional care units.

It's almost the same concept as going to a rehab facility, right? So we have patients who on a hospital setting are sent to rehab so they can feel better before they actually go home. And physicians use the same analogy when they look at a transitional care unit, and say, it makes sense. It also takes that bias I've mentioned earlier away, because physicians tend to now look at a patient as a candidate for a TCU based on if their candidate is for home therapy.

I think by expanding who is a candidate for TCU to everybody, it allows the patient to determine if they want to do home dialysis. And so physicians have really been in support of taking their bias away and giving more patients a chance to at least have the experience of a TCU and eventually choose the best modality for themselves.

Brad Puffer: I would say, Dr. Chatoth, in the example you gave to, unfortunately, we would love to be able to educate patients for the year leading up to when they have kidney failure. But like the patient you described, too many are just finding out suddenly that they have kidney failure.

Dr. Dinesh Chatoth: Exactly. So what are the problems of our patients who crash in a hospital system is a lot of them don't know that they have kidney disease, let alone advanced kidney failure to where they need dialysis. So the information is given to them, and a lot of them consider that as almost a death sentence. When somebody tells someone that you have kidney failure, you need to be on dialysis, it literally is a life-changing event.

So having the option to let that information settle in, and then let the patient know that this is not the end of the world. It's actually beginning of a journey that requires a little bit of support and handholding and education, which you can do it, goes a long way for them to choose what's best for them. And it's long-lasting even beyond that. These patients feel better and they do better long term.

Brad Puffer: Well, this idea of transitional care, as we started with, does not apply just to what we're doing with TCUs in kidney disease. Are there other areas of health care where this model really would apply well? And what can other providers learn from our experience?

Dr. Dinesh Chatoth: So transitional care concept is really about moving a patient who's been just been told about a diagnosis where they feel less empowered to educating them after they feel emotionally ready to receive that education. Another setting where this can be used is oncology, where people are told that they have cancers, where they have to make decisions on the right treatment choices. So oncology is a great place where a transitional care model would be helpful.

And then other areas of transition like hospital transitions to either a home or a skilled nursing facility, having patients understand the transitions and the care models well and be educated on what to expect is really going to be helpful. So I think there are other areas where transitional care models can be used.

Brad Puffer: Well, Dr. Chatoth, I know Fresenius Kidney Care has put a lot of resources and support behind this TCU effort. For you, personally, why are you so supportive of this effort? And are you hopeful about the future?

Dr. Dinesh Chatoth: Well, I'm very hopeful about the future, Brad. I mean, Fresenius mission statement is to provide superior patient centered care that allows a patient to feel empowered and to thrive, and this fits our mission statement very well. Our company has been very focused on increasing the home therapy option for most of our patients. And this allows our patients to experience home dialysis.

Personally, it's great for me to see home therapies such a focus in the company. And then more patients are able to actually experience home dialysis to the fullest.

Brad Puffer: Well, it will be really interesting to follow this effort, this evolution, not just the home dialysis, but through the transitional care unit. And as we always do, I'm sure we'll be looking very closely at just how well these patients do so that we can come back and show what we've learned so others hopefully can implement some of these efforts as well. Well, Dr. Chatoth, it's been absolutely great talking with you. I've learned a lot. I hope a lot of other people will have a better understanding of transitional care. Thank you so much for taking the time.

Dr. Dinesh Chatoth: Well, thank you, Brad. It's been a pleasure talking to you.

Brad Puffer: And to our audience, thank you for joining us. Don't forget, you can find Field Notes on the Apple Store or Google Play, or right here at fmcna.com, where you can also find our annual medical report and other featured articles. We hope you'll come back and join us as we have many more topics to discuss in the weeks ahead. Until next time, I'm Brad Puffer and you've been listening to Field Notes by Fresenius Medical Care. Take care, everyone.