Establishing a Transitional Care Unit in an Academic Center

Background: Transitional Care Units (TCUs), described since the 1980s, focus on patient education, permanent access placement, transplant referrals, and reducing hospital readmissions to improve mortality. Despite these benefits, low adoption is likely due to resource limitations, patient preferences, and implementation challenges. This study assesses the feasibility and outcomes of establishing a TCU at a large academic health center during its first year. Methods: We reviewed data collected, including demographics, transplant eligibility, dialysis modality, access type, and hospitalization details. Figure 1 illustrates the TCU workflow. We also analyzed referrals for patients initiated on inpatient hemodialysis by the dialysis social worker. Results: Out of the 78 patients who initiated outpatient hemodialysis from July 2023 to August 2024, 21 % transitioned to TCU. Among 27 patients analyzed, the mean age was 55 years, and 44% were female. The median time from dialysis initiation to TCU transfer was 7 days. 70% were new to dialysis (incident), and 15% were on peritoneal dialysis at admission. On admission, 52% had tunneled dialysis catheters, 22% with AV fistulas, and 33% with PD catheters. At discharge from TCU, 19% still had a tunneled catheter. The median stay was 99 days. Nearly half (48%) transitioned to home dialysis, and 85% were on PD. During the stay, 74% had no ER visits, and 78% had no hospitalization. 63% were undergoing transplant workup by the end of TCU. Conclusion: The successful establishment of a TCU demonstrated feasibility and positive patient outcomes, including timely access placement and increased utilization of home dialysis. We highlight the potential benefits of integrating transitional care into academic centers and reassure us of the effectiveness of TCUs in improving ESKD management and patient-centered outcomes.Transitional Care Unit workflow