Table 2:

Challenges and mitigation strategies in integrated home dialysis.

Challenge	Mitigation strategies
Patient-level
Lack of awareness of the PD-to-HHD transition	Education programs across the pre-dialysis and dialysis pathway Enroll home-eligible patients in TCUs
Appropriate patient selection for the transition	Multidisciplinary patient evaluations, notably including social worker input
Identifying an optimal moment for a PD-to-HHD transition	Systematic tools to predict the risk of PD failure Enhanced shared decision-making with patients Consider transferring a patient near PD failure to a TCU if HHD not available
Patients’ fears or concerns about home dialysis and the PD-to-HHD transition	Strong and empathic patient–clinician relationships Psychological support Use of patient partners and peer-support groups Patient education programs Recognizing and treating comorbid mental illnesses
Potential home-care burnout after PD failure	Respite programs and temporary semi-autonomous HD Assisted HHD programs
Caregiver burden	Monitoring of caregiver fatigue signs Professional home nursing support Financial remuneration or fiscal advantages for care given by family members
Financial burden of home modalities and inappropriate house setting for home dialysis	Financial support programs for dialysis equipment and home adaptation Community dialysis houses
Center-level
Insufficient physician training and experience in home dialysis and PD-to-HHD transitions	Mandatory and sufficient home dialysis exposure during nephrology fellowship Continuous professional development targeted for home dialysis and home-to-home transitions Mentoring centers and widespread adoption of ECHO initiatives
Insufficient surgical training and poor availability for PD catheters, AV access placement	Enhance training in PD catheter insertion and AVF-AVG placement during surgical and radiological residencies Ensure sufficient access to surgical suites and appropriate payment for these procedures for clinicians performing dialysis center installation
Nursing shortage in home dialysis centers	Develop telehealth and remote monitoring solutions Ensure the attractiveness of dialysis nurse positions Consider and promote the contribution of non-healthcare workers in assisted dialysis programs
Lack of integration between PD and HHD centers	Promote integrated dialysis centers that offer multiple modalities Establish dialysis center networks and integrated care pathways between centers Technological solutions to allow remote visits and monitoring for patients living far away from their dialysis center
System-level
Appropriate payment systems for home dialysis centers	Ensure fair payment schemes for each dialysis modalities that recognize the extra costs associated with home modalities Systematically monitor the impact of payment systems on home dialysis incidence Reimbursement of telehealth visits
Patient volume requirement for financial viability	Appropriately fund fixed costs associated with dialysis centers Adapt payment schemes to ensure financial viability at smaller patient volumes
Performance-related payment discouraging the entry of comorbid patients in home dialysis	Avoid performance-related payments schemes that can discourage the enrollment of comorbid patients Adapt dialysis reimbursement to patient complexity and comorbidities
Systematic discrepancies in home dialysis access	Promote home dialysis in underrepresented communities with education programs and financial support Personalize and individualize training programs (notably to work schedules and literacy level)

AVF, arteriovenous fistula; AVG, arteriovenous graft; ECHO HD, hemodialysis