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Running head: ALAMEDA HHD BUSINESS PLAN

Alameda HHD Business Plan

Jessica Ndegwa

University of San Diego

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ALAMEDA HHD BUSINESS PLAN
Executive Summary

Alameda HHD is a consulting company whose goal is to help hemodialysis (HD) patients

safely transition to performing their own dialysis at home. Home HD as opposed to In-center

Hemodialysis (ICHD) has multiple benefits for patients due to the convenience of increased

flexibility from personalizing the dialysis schedule to fit one’s life. In contrast, ICHD is

associated with higher healthcare costs, a negative impact on clinical and patient-centered

outcomes, unsustainable growth in patient numbers, and inadequate facility HD staff and

infrastructure. Alameda HHD’s mission is to collaborate with dialysis centers in Alameda

County in Northern California to identify patients who are suitable for home HD. Once a patient

who currently receives ICHD is identified for home HD, Alameda HHD helps provide safe and

effective home training for the patient to ensure a smooth transition to dialyzing at home, taking

the workload of such management off the dialysis center.

Estimated start-up costs is $15,000. Projected onset of cash flow is January 2021,

assuming consultation service is requested for two patients. The projected number of patient

consultations for 2021 is 20 patients, with an operating margin projection of $350,000 and

operating costs of $125,820. Business growth from January 2021 to December 2021 is projected

to be greater than 50%. Upfront costs and investment costs are projected to have a 100% return

by March 2021. Successful patient transitions to home HD are projected to lead to an increase in

consultation needs. Thus, business growth is anticipated with expansion to other counties in the

San Francisco Bay Area. Collaboration with dialysis facility administration, nephrologist, case

manager, dietician, and the NxStage Home HD machine provider will result in successful

identification of patients suitable for home HD, as well as an easier and safer transition of such

patients to that modality.

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ALAMEDA HHD BUSINESS PLAN
Company Overview

Alameda HHD is a northern California company serving Alameda county that provides

home HD training to patients with End Stage Renal Disease (ESRD) at home as opposed to at a

facility. According to Rivara and Mehotra (2014), growing evidence supports outcomes for

patients undergoing both peritoneal dialysis and home HD are as good or better than those for

patients undergoing ICHD. The National Institute of Diabetes and Digestive and Kidney

Diseases (NIDDK, 2016) states 661,000 Americans have kidney failure and 468,000 are on

dialysis. According to United States Renal Data System (USRDS) in 2017 among patients being

treated with HD, 98% used ICHD and only 2% used home HD.

The company’s mission is to empower all patients regardless of socioeconomic status,

with adequate training to perform dialysis in the comfort of their home. Once a patient is

identified as meeting criteria for home HD, an Alameda HHD RN will coordinate with the

dialysis facility to arrange for at home HD training sessions. A maximum of 25 sessions for

home HD are offered within a six-week period to comply with CMS reimbursement policy.

According to the National Kidney Foundation (2015), home HD has patient benefits such as

improved post-dialysis recovery, schedule flexibility, increased five-year survival rate,

maintenance of quality of life and employment, improved energy and vitality, and fewer fluid

and dietary restrictions. These benefits concur with the research data reported by Brill (2016)

that stated only 9% of nephrologists chose ICHD when asked about their preference if they

required dialysis themselves.

The company’s objectives are to address the inequities in access to home HD and

increase its utilization. The plan is to partner with dialysis centers certified by CMS to offer this

option to patients and assist them in making a seamless transition to this modality. Successful
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ALAMEDA HHD BUSINESS PLAN
home HD adoption and utilization requires adequate education and support by CMS and

nephrologists. Investment in furthering home HD is beneficial to improve ESRD patient

outcomes, decrease financial burden from workforce affected, and decrease health care spending

by improving ESRD management. As the population affected by ESRD increases, with few

achieving successful recovery with kidney transplants, it is imperative to support this

underutilized treatment modality for the betterment of ESRD management.

Business Description

Alameda HHD is a company that seeks to increase the use of home HD as opposed to In-

center Hemodialysis (ICHD) by performing at home training with the patient and a care partner

if available. Performing dialysis in the comfort of one’s home negates the need to drive to a

facility, creates greater individualized care from increased schedule flexibility, promotes

maintenance of quality of life and employment, has a lower infection risk, and increases patient

empowerment from control of care. Alameda HHD working in conjunction with the patient’s

dialysis clinic, helps the patient set up the equipment, supplies, and provides ongoing

personalized training at the patient’s home for a specified number of sessions. Assisting the

patient from the onset with this setup in their home eliminates stress and pressure associated with

this nuance. The nurse brings the dialysis machine to the patient’s home, locates the water source

(a simple faucet or under-sink connection), electric outlet, and designated area where the patient

will conduct dialysis. The nurse also helps the patient determine a storage space for the dialysis

equipment and supplies, which will then be set up for monthly delivery. The dialysis equipment

used will be NxStage System One, the training will be done by certified dialysis registered

nurses, equipment and supplies will be paid for according to insurance coverage.
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ALAMEDA HHD BUSINESS PLAN
Opportunity. Alameda HHD will serve dialysis patients in Alameda county. Further

expansion of home HD is in high demand, as there is a growing population of ESRD patients,

few kidney transplants available, increased demand for more dialysis facilities, and an increase

in patients that can independently conduct dialysis at home. According to the Healthy Alameda

County Website (2020b), the percentage of Medicare beneficiaries who were treated for chronic

kidney disease increased from 14.9% in 2010 to 24.7% in 2017.

Product overview. The service offered is provision of initial home dialysis supplies and

training at home for HD. Alameda HHD takes on the responsibility of setting up initial

equipment and supplies, and coordinates with the dialysis clinic, nephrologist, and social worker

to help the patient focus solely on the most important aspect, which is the home dialysis training.

Once the training sessions are complete, Alameda HHD develops a plan of care for the patient,

which has direct input from their nephrologist at the dialysis clinic, dietitian, and social worker.

Alameda HHD nurse will arrange to check-in with the patient at their monthly clinic visits and

also offer free phone consultations for questions or concerns that may arise.

Key participants and management team. NxStage will be the specific company whose

home HD equipment (NxStage System One) will be provided to the patient. Alameda HHD will

work in conjunction with the patient’s dialysis clinic, the patient’s nephrologist, social worker,

and dietician.

Clinical or Regulatory compliance. To comply with the federal Medicare conditions for

coverage for ESRD, Alameda HHD will only work with CMS certified dialysis clinics approved

to provide home HD and will employ only Certified Dialysis Nurses (CDN) to conduct the

training and ongoing follow-ups. NxStage System One dialysis machines are approved by the
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ALAMEDA HHD BUSINESS PLAN
Food and Drug Administration (FDA) for solo home HD therapy (without the mandate for a care

partner to be present when dialyzing).

Pricing. According to the CMS website (2019), Medicare Part B covers 80% of dialysis

and provides reimbursement for the cost of a home machine for HD, equipment, and supplies.

The patient’s secondary health plan covers the remaining 20%. Medicare also pays for up to 25

home HD training sessions, which typically last three to five hours. This payment is for staff

time, use of the machine, supplies, bundled labs and drugs, and training materials. According to

Home Dialysis Central (2020), Medicare will routinely pay for up to three home HD treatments a

week but may pay for more treatments if the patient’s nephrologist provides an indication for the

need for more sessions. Alameda HHD will be paid for providing consultation service and

coordinating initiation of home HD for a clinic’s patient. According to the USRDS (2019), one

year of HD can cost up to $72,000. With this statistic in mind, the consultation fee for Alameda

HHD services will be prorated at a retainer basis, with a monthly fee of $10,000 per patient. This

cost covers the nurse’s salary (based on hours conducting the in-home training), commute

expense, and nurse training on NxStage equipment. Administrative, marketing and consulting

operations conducted by the CEO, will be based from my home office. Two CDNs paid $60 per

one hour of training conducted at the client’s home will be hired. Projected revenue from one

client is $10,000 for a one-month period of training (12 sessions, three per week). Cost of labor,

such as employee salary and commuting expenses, is estimated at $4,000 every month. Monthly

operating expenses, taxes, and legal fees is estimated at $2,000. Projected gross profit is

estimated at $4,000 with a gross margin of 40%. Further expansion of Alameda HHD services to

multiple CMS certified dialysis clinics and other counties is the future fiduciary vision for this

company.
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ALAMEDA HHD BUSINESS PLAN
Market Analysis

Industry type. Alameda HHD is a company that seeks to offer home HD training to

ESRD patients that have the capability of handling that modality at home, which has been

associated with improved quality of life and greater schedule flexibility. Patients are able to live

to dialyze rather than dialyze to live.

Demographics. The target market for Alameda HHD is ESRD patients on HD that have

the resources required to transition to home HD.

Geographic location. At this moment, this service will be offered to residents of

Alameda county in Northern California. According to the Centers for Disease Control and

Prevention (CDC) in 2016, nearly 125,000 people in the United States started treatment for

ESRD, and more than 726,000 (two in every 1,000 people) were on dialysis (CDC, 2019).

According to the Healthy Alameda county website, as of 2020, there are 1,682,509 people in

Alameda (Healthy Alameda county, 2020a). Taking the CDC dialysis ratio into account, there

are approximately 3,365 dialysis candidates in Alameda for the service we are seeking to

provide.

Buyer characteristics. The target patient is one that has HD at a dialysis center that is

CMS approved to offer home HD. The patient has adequate insurance coverage for this modality,

shows interest in home HD, meets home requirements, wants to maintain quality of life, income

or employment by having better flexibility with their treatment, and shows competency, such as

never missing dialysis treatments and is compliant with medication and lab or clinic

appointments.

Market segmentation. Among patients being treated with HD, 98% used ICHD, and 2%

used home HD. In 2017, use of home HD was 120.8% higher than in 2007. Despite the large
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ALAMEDA HHD BUSINESS PLAN
proportional rise in home HD, its overall use was only 4% of all incident ESRD patients

receiving dialysis in 2017 (USRDS, 2019). These statistics show there is a demand for home HD

that has not been met. Alameda HHD engages and empowers patients by providing adequate

training to perform home HD and help improve and maintain quality of life despite having a

chronic disease.

Competition. The biggest competitor to its service is dialysis centers that provide in-

center dialysis. “It’s more appealing for a dialysis company to add patients to a center where one

machine can accommodate multiple patients than it is to provide new services to each patient at

home” (Luthi, 2019). The company seeks to work in conjunction with dialysis centers to provide

HHD service to patients, so the threat to the company would be if there is any resistance from the

dialysis center due to either fear of a loss of patient/clientele to home HD or an unwillingness to

spend additional funds and time to become CMS-certified to provide home HD to patients. To

combat such pushback, the company will provide a market analysis report to the dialysis centers

that details CMS reimbursement for home HD services. The plan will also discuss advantages of

consultation services, such as reduced staffing requirements for the facilities. The company will

provide clinicians data on long-term reduction of treatment costs associated with home HD, as

well as improved patient outcomes from early referral to our home HD service. Additionally,

using social media to inform patients of the benefits of home HD, would empower them to hold

their dialysis centers accountable for offering all treatment options and not just in-center dialysis.

See Table 1 for the company’s full Strengths, Weaknesses, Opportunities, and Threats (SWOT)

analysis.

Table 1

SWOT Analysis
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ALAMEDA HHD BUSINESS PLAN
STRENGTHS WEAKNESSES
-Capabilities – the company is unique as it -Dependent on consultation from dialysis
will handle all the aspects involved in centers
transitioning patients from in-center HD to -Cash flow with the business startup -
home HD and coordinate with the patient’s advertising services, hiring CDNs, liability
nephrologist, social worker, and dietician. insurance
-Advantage -patient empowered to perform
HD in the comfort of their home; maintain
quality of life, employment, and diet; able to
travel and optimize flexibility, i.e. choose
location, frequency, and time of HD
-Assets - CDNs provide HHD training
-Experience- CDN to provide training on
NxStage one HD machine use
-Value - Takes the responsibility of
transitional home HD training off the dialysis
center

OPPORTUNITIES THREATS
-More patients diagnosed with ESRD every -Obstacle – if CMS reimbursement for home
year, demand for home HD is uncapped HD does not improve, there will be less
-Emerging technology will result in better incentive for dialysis centers to become CMS
user-friendly home hemodialysis machines certified to offer home HD services
that will lead to an increase in demand for -Dialysis centers once reviewing our service
home HD training. chooses to “cut out the middleman” and
-Expansion of telehealth services will make provide their own training
home HD a more viable option for clinicians -Liability concerns
to recommend to their patients
-Partnering with dialysis centers approved by
CMS for home HD will be key in obtaining
potential clients
-The shift toward patient-centered care will
increase the need for home HD
Note. Strategic analysis of Alameda HHD business venture.

To maintain a loyal customer base, Alameda HHD will provide monthly updates on their

patients’ progress, including the cost-savings achieved from offering this modality. Alameda

HHD will offer lifetime free phone consultations to the patients who receive services to address

any questions or concerns. Future technology advances will result in better, simpler user-friendly

home HD machines. This will increase the demand for home HD. Telehealth expansion will

make it viable for nephrologists to communicate with patients performing home HD which will
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ALAMEDA HHD BUSINESS PLAN
drive the demand for our services. Demand for home HD associated with an increase in ESRD

patients will result in CMS reimbursement changes that will support its use and hopefully offer

more incentives for dialysis centers to offer this modality.

Financial Plan

Projected start-up costs. Estimated start-up costs of $15,000 will be obtained from a

business line of credit, which has the advantage of only paying interest on the amount used. An

interest rate of 10% will be the cost of obtaining funding ($1,500). The business will be set up in

October 2020, and by January 2021, it will have its first two patient consultations for home HD

(Net income $8,563).

Staffing plan. For the first year, the employees will include myself in the administrative

role and two dialysis nurses. I will be tasked with managing the budget, payroll, marketing and

coordinating consultations between the dialysis center, the patient’s nephrologist and social

worker. The dialysis nurses are required to have a CDN credential, which dictates they have at

least 2,000 hours of nephrology experience. Once hired, they will undergo a two-day training

offered by NxStage to review NxStage System One, the specific dialysis machine that will be

used by the patients at home. The CDNs will be paid $60 per hour. Estimated hours of home HD

training of patients per week is 18 hours. Projected staffing costs for the first year will be

$120,00 for two CDNs and myself.

Cash flow and budget. The business will be consulted to train up to 20 patients for the

first year. The revenue stream will primarily come from patient consultation. The projected fixed

cost is $10,000 per patient referral for 8 weeks of HHD training. Cash will begin to flow

beginning the first month, in January 2021, with a sales forecast/net income of $8,563 for that

month. By December 2021, the company will be training up to four patients every month (sales
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forecast of $206,646), a 24% increase from January 2021.Variable costs include commuting

expenses, advertising and marketing expenses. The operating margin projection for the year 2021

is $350,000. The operating costs projection for the year 2021 is $125,820.

Projected profit and loss. Once the business starts getting more patient consultations as

projected in Table 2, expansion into a second county would be considered, which would

potentially create the need for additional CDNs. During the first year, the anticipation is by

December, four patients per month will be trained. To be budgetarily responsible, the company

will only require two nurses to handle the four patients. If there is a steady consultation for

services, less advertising funds will be required. Projected loss is not anticipated, but any loss of

patient referral will result in less profit. As long as there are two patient referrals a month, profit

is expected.

Fundraising or grant opportunities. Upfront costs that will be avoided include rental

space and furniture, as the business will be based from a home office. Potential return on

investment will offset the start-up costs. Potential risks, such as employee safety and legal

matters will be an ongoing risk. Employee safety will be managed by performing routine risk

assessments and establishing a protocol and policy for potential hazards. Each employee will

also be provided with a cell phone to check in with the CEO upon arriving and leaving the

patients home. To manage legal matters, the business will have a monthly stipend for legal

consultation fees. This new home HD service will significantly impact ESRD patient outcomes

by providing greater flexibility to maintain quality of life. It is also associated with fewer

hospital admissions (cost avoidance) due to increased patient involvement in their care and

having the ability to dialyze more frequently, as opposed to HD at a facility. Opportunities for
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ALAMEDA HHD BUSINESS PLAN
outside funding may arise if as a result of a successful venture, the service provided will be a

sought-out service statewide.

Summary of assumptions. Beginning in January 2021, the company will have two

patient referrals from the dialysis center. That number will steadily increase through the year so

that by December, four patients will be managed each month. Only two CDNs will be required

for the year 2021. No projected losses will be incurred, as there will be a steady number of

referrals each month. The tax rate is 10% from January to March, and 12% from April to

December. The business will have a significant operating margin for 2021 that will necessitate

expansion into additional counties.

Table 2

Start-Up Costs

START-UP COSTS ALAMEDA HHD June 19, 2020

COST ITEMS DATE DUE BUDGET ACTUAL
 
ADMINISTRATIVE/G
ENERAL
Licenses/Registration Oct 2020 $200
Permits Oct 2020 $100
Insurance Oct 2020 $100
Legal Oct 2020 $50
Business Consultant n/a n/a
NxStage two day
Training Oct 2020 $150
workshop $75/person
Software (General) n/a
Miscellaneous n/a
LOCATION/OFFICE
Space Rental/Lease n/a
Utility Costs $50
Telephone Set up &
$600
Annual Cost
Furniture n/a
Medical Equipment n/a
Hardware n/a
Software (CRM, imaging
n/a
etc.)
Installation Fees n/a
Start Up Inventory
n/a
(pharmaceuticals)
Nurse Supplies (gloves, $20
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ALAMEDA HHD BUSINESS PLAN
etc.)
Miscellaneous n/a
MARKETING
Logo, branding, website $300
Advertising/listing fees $500
Printed Marketing
$100
materials
Internet/Web marketing n/a
Trade Shows n/a
Networking events n/a
Miscellaneous n/a
LABOR EXPENSES
$60/hour for CDN(2) +
Payroll $10,000
CEO
Training n/a
Miscellaneous $160 Commuting expense
OTHER  
Contingency
  $3220
reserve/work cell phones
ESTIMATED START-
  $15,000  
UP BUDGET
Note. Start-up costs due by October 2020

Table 2

Profit and Loss Sheet

PROFIT AND LOSS

                         
SHEET TEMPLATE
ALAMEDA HHD JUNE 19, 2020
 

MA MA AU OC NO DE
REVENUE JAN FEB APR JUN JUL SEP YTD
R Y G T V C
 $20, $20,  $20, $30,  $30, $30, $30,  $30, $30, $40, $40, $40, $350,0
Service Revenue
000 000 000 000 000 000 000 000 000 000 000 000 00
Less (Discounts, Billing
Errors, Declined insurance,  $0  $0  $0 $0  $0 $0  $0  $0  $0  $0  $0  $0 $0
etc.)
Estimated sales  $0  $0  $0  $0  $0  $0  $0  $0  $0 $0  $0  $0 $0

Other Revenue  $0  $0 $0  $0  $0  $0  $0  $0 $0  $0  $0 $0  $0
 $10, $20,  $20,  $30,  $30,  $30,  $30, $30,  $30,  $40,  $40,  $40, $350,0
Net Sales
000 000 000 000 000 000 000 000 000 000 000 000 00
Cost of Goods Sold  $0  $0 $0 $0  $0 $0 $0  $0  $0 $0  $0 $0  $0
$20, $20, $20, $30, $30, $30, $30, $30, $30, $40, $40, $40, $350,0
Gross Profit
000 000 000 000 000 000 000 000 000 000 000 000 00
 
MA MA AU OC NO DE
EXPENSES JAN FEB APR JUN JUL SEP YTD
R Y G T V C
 $17  $17  $17  $17  $17  $17  $17  $17  $17  $17  $17
Administrative General $175  $2100
5 5 5 5 5 5 5 5 5 5 5
 $10  $10  $10  $10  $10  $10  $10  $10
Location/Office $100 $100  $100  $100  $1200
0 0 0 0 0 0 0 0
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ALAMEDA HHD BUSINESS PLAN
Marketing  $50  $50 $50 $50 $50  $50  $50  $50 $50  $50  $50  $50 $600
 $10, $10, $10,  $10,  $10,  $10, $10,  $10,  $10,  $10,  $10,  $10, $120,0
Labor
000 000  000  000 000 000 000  000 000 000 000 000 00
 $16  $16  $16  $16  $16  $16  $16  $16  $16  $16  $16
Other $160 $1920
0 0 0 0 0 0 0 0 0 0 0
 $10,  $10, $10, $10,  $10,  $10,  $10,  $10,  $10,  $10,  $10,  $10, $125,8
Total Expenses
485 485 485 485 485 485 485 485 485 485 485 485 20
 $9,5  $9,5 $9,5  $19, $19, $19, $19, $19, $19, $29, $29,  $29, $234,1
Income Before Taxes
15 15 15  515 515 515  515  515  515 515 515 515 80

Income Tax Expense $234 $234 $234 $234 $234 $234 $354 $354 $354 $27534
$952 $952 $952
2 2 2 2 2 2 2 2 2
 
$856  $85 $856 $17, $17,  $17, $17,  $17, $17,  $25, $25, $25, $206,6
NET INCOME
3 63 3 173 173 173 173 173 173 973 973 973 46
 
Note. Profit and loss projection for January 2021 to December 2021

Operating/Implementation Plan

Timeline:

● July 2020 - September 2020: During this time, the company will ensure license

and registration are completed, legal counsel is consulted, work policies and

protocols are established, and the home office is completely setup.

● September 2020 - December 2020: Two CDNs are hired and NxStage System

One training is completed. Consultation acquired from an Alameda-based dialysis

center that has CMS approval for home HD. The business associate agreement is

established.

● January 2021: First patient consultation for home HD training and the onset of

business cash flow occurs.

Key employees and organization. CEO/Home therapy program manager, who is CDN

certified, has completed training on NxStage System One machine. Is responsible for the budget.

Coordinates with the patient’s dialysis center, nephrologist and social worker. Is the main

resource for patients who receive the business phone number for questions and concerns

regarding their home HD. Dialysis nurses are required to have California RN license, CDN

certification, Basic Life Support (BLS) certification, and complete training on the NxStage
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ALAMEDA HHD BUSINESS PLAN
System One machine. The home-based business will be conducted in Berkeley, CA - Alameda

county. See Figure 1 for the organizational chart.

Dialysis RN
CDN certified
CEO BLS certified
CDN certified
(OWNER) Dialysis RN
CDN certified
BLS certified

Figure 1. Organizational Chart. Depicts key employees of Alameda HHD.

Recruiting. Advertisements and job postings will be made on www.nurse.com.

Actual work required. The CDN will be deployed to a patient’s home within Alameda

county. The patient should have received all the dialysis supplies in advance. The CDN will set

up home HD and provide safe and effective training to the patient on the following tasks: use of

home HD and water machines; proper disposal of needles, syringes, treatment tubing and

dialyzers; how to use and care for dialysis access; troubleshooting any issues that may occur

during treatment; resources available to address questions and concerns. The CDN will comply

with set policies and protocols and standards of home HD. The CDN will communicate patient-

related issues to the physician and adverse patient events to the dialysis clinic and nephrologist

as needed. Training per patient will be conducted in five-hour sessions, three times a week for

eight weeks. Patient will then receive a certificate once training is complete.

Stakeholders. The following entities are stakeholders in the company: Fundbox, an

online lender for business line of credit; the Alameda-based dialysis center; Alameda HHD

employees, which are CEO and two CDNs; and patients that receive consultation services.

References
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ALAMEDA HHD BUSINESS PLAN
Brill, A. (2016, March). Economic benefits of increased home dialysis utilization and innovation.

Retrieved from https://www.homedialysis.org/documents/spotlight/mga_home_dialysis_

paper_for_release.pdf

Centers for Disease Control and Prevention (2019, March 5). Chronic kidney disease in the

United States 2019. Retrieved from https://www.cdc.gov/kidney/disease/pdf/2019_

National-Chronic-Kidney-Disease-Fact-Sheet.pdf

Healthy Alameda County. (2020a). 2020 demographics. Retrieved from http://www.healthyalam

edacounty.org/demographicdata?id=238

Healthy Alameda County. (2020b). Chronic kidney disease: Medicare population. Retrieved

from www.healthyalamedacounty.org/indicators/index/view?indicatorId=2056&localeId

=238

Home Dialysis Central (2020). Paying for treatment. Retrieved from https://hemodialysis.org/ho

me-dialysis-basics/paying-for-treatment

Luthi, S. (2019, March 4). Azar: Kidney dialysis needs to move to patient homes. Modern

Healthcare. Retrieved from https://www.modernhealthcare.com/payment/azar-kidney-dia

lysis-needs-move-patient-homes

National Institute of Diabetes and Digestive and Kidney Diseases (2016, December). Kidney

disease statistics for the United States. Retrieved from https://www.niddk.nih.gov/health-

information/health-statistics/kidney-disease

National Kidney Foundation (2015). Home hemodialysis. Retrieved from https://www.kidney.or

g/atoz/content/homehemo

Rivara, M. B., & Mehotra, R. (2014). The changing landscape of home dialysis in the United

States. Current Opinion in Nephrology and Hypertension, 23, 586-591. doi:10.1097/MN

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H. 0000000000000066

U.S. Centers for Medicare & Medicaid Services (2019). Medicare benefit policy manual:

Chapter 11: End stage renal disease. Retrieved from https://www.cms.gov/Regulations-a

nd-Guidance/Guidance/Manuals/downloads/bp102c11.pdf

U. S. Renal Data System. (2019). US renal data system 2019 annual data report: epidemiology

of kidney disease in the United States. Retrieved from https://www.usrds.org/2019/view/

USRDS_2019_ES_final.pdf