A Softer Landing
Most patients crash into dialysis: a hospital emergency, a lifelong diagnosis delivered in a single overwhelming week, and a treatment path chosen by default. At a coastal Georgia clinic I invented, designed, and built the company’s first transitional care unit — and roughly 56% of patients who came through it chose home dialysis, against a ceiling near 30% in the units that followed.
All figures drawn from the public record; where results remain internal, they are described directionally. Visuals recreated as abstractions — no client artifacts or confidential data appear on this page.
The crash landing
Most people arrive at dialysis through an emergency. They are living their lives, and then a hospital tells them their kidneys have failed and will not recover — dialysis for life, or a transplant. It is one of the most abrupt diagnoses in medicine, and it lands on patients at their least receptive: severely uremic, toxins clouding their thinking, in no condition to absorb the most consequential health decision they will ever make. Most have never heard how dialysis actually works. And in those first days the system quietly makes the choice for them, defaulting them into conventional in-center care — a model built in the 1980s for throughput, efficient by design and intimidating by consequence.
This sat inside one of the largest strategic pushes in the field: a company wide and industry wide drive — across the US and many countries — to grow home therapy to at least half of all outpatient dialysis. The logic converges from every direction: home produces better outcomes and lower hospitalization, payers reimburse it more favorably, and it spares the enormous cost of building and running in-center clinics. Better for patients, better for the business, better for the health system. Growing home was the goal everywhere — and the mechanism to actually do it was missing.
Transitional care was being explored in the medical literature as that mechanism: a gentler on ramp. Within Fresenius — in US home dialysis and across the company globally — no one had ever made one work.
The window everyone wasted — and the choice nobody offered
Two truths sat underneath the crash landing. First, the moment a patient is most overwhelmed is the exact moment their path gets chosen — so the standard model spends the most decision critical weeks of a patient’s life on paperwork and a default chair assignment. Second, the default has enormous downstream cost. Patients routed into in-center care rarely leave it, even though home dialysis offers a life the in-center model cannot: the flexibility to travel, to keep a fulltime job, to recover a normal life instead of surrendering three days a week and the exhausted evenings around them.
The stakes ran in the same direction for everyone. Home therapy produces better patient outcomes and quality of life — and, with far less labor per patient, it is meaningfully more profitable than conventional in-center care, home hemodialysis most of all. Better for patients and better for the business pointed the same way. What was missing was a setting that let patients actually see the choice — because patients believe what they can see, not what a pamphlet promises.
Three ways to fix the landing
Education first — and the courage to question the model
Education first, for every patient, regardless of where they landed: the unit’s job was to make sure no one chose their treatment by default. Patients interacted with the machines, learned self care around their own treatment, moved toward home training, and saw — in the next bay — other patients running their own care. The most persuasive modality education in dialysis is a patient watching another patient do it.
The hard part was not clinical. It was institutional. The entire business — admissions design, operational models and resources, regulatory, the reflex to assign a chair on arrival — was engineered around in-center referral. Building a unit that steered patients toward home meant questioning the model the company was built on, and that upset people who had never had reason to question it. It took real conversations and the full backing of the group’s senior executive to navigate them. Doing what was right for the patient meant being willing to challenge the status quo that paid for everything.
A unit, a blueprint, and a pilgrimage site
- ✓The company’s first transitional care unit — my invention, builtA dedicated, education first unit at a coastal Georgia clinic — the first ever to succeed in US home dialysis, and across the company globally.
- ✓Education first for every modalityStructured exposure to every path, including transplant, with hands on time on the machines and access placement handled inside the window — so no patient chose by default.
- ✓Self care by designPatients learned to set up and run their own treatments on the way to home training — confidence built daily, not promised later, with self care patients in view of new arrivals as living proof.
- ✓The 2.0 replication blueprintA three bay, eight station design expandable to sixteen patients, with a staggered shift architecture that eliminated home machine turnover — engineering the patient centric unit to outperform conventional in-center care financially.
- ✓A model that traveled — and enduredLeaders from the president down traveled to see it. The concept was later formalized into the enterprise’s clinical program definitions and reappeared in my own later market programs and the connected health roadmap. The original unit still runs today — the longest standing transitional care unit in the company.
What the landing returned
Roughly 56% of patients who came through the unit chose a home modality — nearly double the ceiling of about 30% that later transitional units would reach. The market effect compounded: on the strength of this work, the region grew home therapy to the highest home-to-in-center patient ratio of any region in the Southeast Group — first out of them all. Better outcomes for patients, a better life, and a more profitable model for the business, all from the same design (specific financial returns remain internal and confidential). The unit the company had never been able to build, built once and still running — and the foundation of how I have thought about patient first design ever since.
A soft landing is a system, not a sentiment.
What this page doesn't show
The operating playbook — how the work was sequenced, how champions were won, and how the change was made to stick. That part isn't a storyboard. It's a conversation.