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Transitional Dialysis : The Next Frontier

Martin J Schreiber MDCMO, Home ModalitiesDaVita Kidney CareDenver, Colorado

Annual Dialysis ConferencePatient Centered Choices3:00 ‐3:20PM March 17,2019

Disclosures

• CMO, Home Modalities ( full time employee of DaVita Kidney Care)

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Transitional Unit:

What is a Transitional Unit?

Why is a Transitional Unit  Needed?

What is different about the Transitional Unit?

Getting started: Putting the pieces in place.

Summary comments

• Program designed to “ease” patients into dialysis

– Offers patients in transitional care:

Time to recover medically

Time to adjust to the new normal

Time to make educated choices about their future

Time to answer all their questions about dialysis

Time to determine what modality is best for theIndividualize dialysis script to decrease risk for cardiovascular events and hospitalizations during the first sevwks. on dialysis 1,2 1 Kidney International (2014) 86, 392–398, 1 Kidney International (2015) 88, 1117–1125; doi:10.1038/ki.2015.117; published online 29 April 2015. 2 Predictors of early mortality among incident US hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Bradbury BD, Fissell RB, Albert JM, Anthony MS, Critchlow CW, Pisoni RL, Port FK, Gillespie BW. Clin J Am Soc Nephrol. 2007 Jan;2(1):89‐99

What is a transitional dialysis program?

Reports on a Transitional  Program:limited reports, little outcome information ,model variation

Semin Dial. 2018 Jan;31(1):82‐87

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Transitional Care Program : Education Curriculum

Courtesy Bob Lockridge MD :Multi center Transitional Program Study: A multicenter, prospective study to determine how a 4‐week patient education program in a transitional care unit influences the choice of dialysis modality at treatment initiation

Add modules as needed >4 wks

© 2017 DaVita Inc. All rights reserved. Proprietary and confidential. For internal use only.

• Unplanned patients – Start in ICHD default

– Uneducated and limited shared decision making

– Poor risk profiling

– Lack of aligning modality with patient

• Pre-dialysis education is limited

• Lack of ICHD Team education on Home

• No systems thinking approach

• ICHD Medical director doesn’t drive intense unbiased education for informed choice

• Lack of individualized dialysis start:’ “imprecision medicine”

Transitional is differentiated from standard approach to incident dialysis

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Standard Approach Transitional

• Unplanned patients – Treatment is hemo but modality initially

considered “undecided”-transitional

– More intensive unbiased education for more patients/all modlaities

– Extended evaluation process: Frailty, PAM, cardiac risk, depression screening, PROM,RRF preservation

– Greater individualization of dialysis Rx (e.g. frequency, UF rate) and ability to avoid deleterious effects such as hypo-perfusion and end organ stunning

– Patient enabled to select modality in shared decision by end of 4 weeks

– Permanent access placement

• Planned start patients

Why is a transitional Program critical to improving US Dialysis outcomes??

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>50% of patients “crash” into dialysis

Nearly all of them go in-center (default)

ICHD unit is the first time many patients receive meaningful modality education

Why do we need a change in CKD5 to ESRD Transition of care??

Song MK, Lin FC, Gilet CA, Arnold RM, Bridgman JC, Ward SE. Patient perspectives on informed decision‐making surrounding dialysis initiation. Nephrol Dial Transplant. 2013;28:2815‐2823.  

2 out of 3 US dialysis patients feel like they didn’t have a choice of 

modality.

© 2018 DaVita Inc. All rights reserved. Proprietary and confidential. For internal use only.

• Mortality and hospitalization risk is heightened at initiation of dialysis1-3

• Similar models utilizing nurse case managers to provide bi-weekly 1:1 patient and self-care education resulted in up to 40% decreased mortality4-6 during first 90 days.

Strong clinical and operational evidence of potential benefit

Clinical and operational evidence

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1. Chan KE, Maddux FW, Tolkoff-Rubin N, Karumanchi SA, Thadhani R, Hakim RM. Early outcomes among those initiating chronic dialysis in the United States, Clin J Am Soc Nephrol 6: 2642-2649, 2011.2. Eckardt KU, Gillespie IA, Kronenberg F, Richards S, Stenvinkel P, Anker SD, Wheeler DC, de Francisco AL, Marcelli D, Froissart M, Floege J; ARO Steering Committee High cardiovascular event rates occur within

the first weeks of starting hemodialysis.Kidney Int. 2015 Nov; 88(5):1117-25. Apr 29.3. Wetmore JB, Gilbertson DT, Liu J, Collins AJ Improving Outcomes in Patients Receiving Dialysis: The Peer Kidney Care Initiative. Clin J Am Soc Nephrol. 2016 Jul 7;11(7):1297-304.4. Kamyar Kalantar-Zadeh, Csaba P. Kovesdy, Elani Streja, Connie M. Rhee, Melissa Soohoo, Joline L.T. Chen, Miklos Z. Molnar, Yoshitsugu Obi, Daniel Gillen, Danh V. Nguyen, Keith C. Norris, John J. Sim and

Steve S. Jacobsen, Transition of care from pre-dialysis prelude to renal replacement therapy: the blueprints of emerging research in advanced chronic kidney disease. Nephrol Dial Transplant (2017) 0: 1–85. Wingard RL, Chan KE, Lazarus JM, Hakim RM. The "right" of passage: surviving the first year of dialysis.Clin J Am Soc Nephrol. 2009 Dec; 4 Suppl 1:S114-20. 6. Wingard R. Reducing early mortality in patients on dialysis: lessons from the RightStart program.; Nephrol Nurs J. 2009 Mar-Apr;36(2):215-20

Mortality Hospitalization

• Transitional model enables more patients to make an informed modality choice

• Many more patients choose home therapies thru informed choice. While results vary >% of patients choose PD vs HHD.

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Patients are ~2X as likely to die or be hospitalized during first weeks of dialysis.

PD 27%

ICHD 51%

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Potential Challenges for a Successful TCU

• ?ideal model/site of delivery

• Physician referral pattern

• Ability to get patients to travel to TCU program ( geographic challenges)

• Increased labor costs

• Challenges to educate in crisis ( ICHD unit)

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Transitional Program requires System/Culture Change: US Dialysis System

Wong LP. Clin J Am Soc Nephrol 2018

Clin J Am Soc Nephrol 13: 655–662, 2018.

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Critical components to the Transitional Program

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Practice belief and 

commitment

Design in setting: systems thinking

Evaluation

Admission 

Prescription design

Education/tracking

Transition/Tracking 

Where Do We Start?1. Analyze your local process

2. Form a “can do it team”

3. Create a shared vision

4. Diagnose silos / barriers

5. Operationalize process

6. Team incentives + accountability

7. Medical directors lead change + change mgmt.

8. Measure impact 

ICHDICHD

DocsDocs

HomeHome

Dialysis TeamDialysis Team

Beer M et al. Why Leadership Training Fails. Harv Bus Rev. Oct 2016: 50‐57

© 2017 DaVita Inc. All rights reserved. Proprietary and confidential. For internal use only.

Transitional Dialysis Program

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PCP

Nephrologist OPD

ER/Hospital

1Patient Intake

4 Intense Management

Process

5Path Forward

2Initial

Discussion Points

3Site

Is patient a HOME Candidate

Is HOME Program available with HD Space

Is there an ICHD POD Transitional Program

Is there a regional micro transitional Start Unit

No

No

Yes

Micro Clinic

ICHDPod

Home Program

• Individualized prescription 3-5 Treatments/Wk +

• Intense Multi-disciplined Assessment

• Family Integration• Training Modules• Education Modules*• Permanent access planning• Chart Documentation

• Support of ADD or MNOrder menu• Shared Decision re:

modality selection• Weekly Physician note

• Billing• Training• Treatments

patient types: Pt undecided (no access) urgent start,Pt decided, no accessPt decided, access in placePt home candidate, undecided, no access

+ADD vs. MFD Medical necessity order menu* Social worker, Nurse, PCT, Dietitiano HHD/PD training modules (generic content + modality specific)

• Modality election• Modality specific

training: initial to completion (PD 15 days, HHD 25 days)

• Auditing/compliance• Documentatio

n• Billing

• Data tracking: Results

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Pre-determined selection criteria *

Open to all patient (planned and unplanned)

Patient utilization will be based on

patient choice to utilize program

Decide on Patient Types

* Failed PD, HHD, Tx; crashers;CKD5 transition 

Summary Comments: Transitional Care Unit (TCU)

1. Changing the model of how patients transition to starting dialysis is critical to patient outcomes2. Being successful in operationalizing a TCU requires recognition that it is not about changing one element but multiple components  in the standard process3. Develop a Systems Thinking approach to understanding and implementing change

(nephrology practice culture , initial patient assessment, education: patient and  dialysis team (Home /ICHD),access planning,  operations, tracking patient status during and after completion of program.