Contemporary nephrology practice is heavily weighted toward in-center hemodialysis, reflective of decisions on infrastructure and personnel in response to decades of policy. The Advancing American Kidney Health initiative seeks to transform care for patients and providers. Under the initiative’s framework, the Center for Medicare and Medicaid Innovation has launched two new care models that align patient choice with provider incentives. The mandatory ESRD Treatment Choices model requires participation by all nephrology practices in designated Hospital Referral Regions, randomly selecting 30% of all Hospital Referral Regions across the United States for participation, with the remaining Hospital Referral Regions serving as controls. The voluntary Kidney Care Choices model offers alternative payment programs open to nephrology practices throughout the country. To help organize implementation of the models, we developed Driver Diagrams that serve as blueprints to identify structures, processes, and norms and generate intervention concepts. We focused on two goals that are directly applicable to nephrology practices and central to the incentive structure of the ESRD Treatment Choices and Kidney Care Choices: (1) increasing utilization of home dialysis, and (2) increasing the number of kidney transplants. Several recurring themes became apparent with implementation. Multiple stakeholders from assorted backgrounds are needed. Communication with primary care providers will facilitate timely referrals, education, and comanagement. Nephrology providers (nephrologists, nursing, dialysis organizations, others) must lead implementation. Patient engagement at nearly every step will help achieve the aims of the models. Advocacy with federal and state regulatory agencies will be crucial to expanding home dialysis and transplantation access. Although the models hold promise to improve choices and outcomes for many patients, we must be vigilant that they not do reinforce existing disparities in health care or widen known racial, socioeconomic, or geographic gaps. The Advancing American Kidney Health initiative has the potential to usher in a new era of value-based care for nephrology.

当代肾脏病学实践在很大程度上偏向于中心血液透析，这反映了响应数十年政策的基础设施和人员决策。推进美国肾脏健康计划旨在改变对患者和提供者的护理。在该倡议的框架下，医疗保险和医疗补助创新中心推出了两种新的护理模式，使患者的选择与提供者的激励措施保持一致。强制性 ESRD 治疗选择模型要求指定医院转诊区域的所有肾脏病学实践参与，随机选择美国所有医院转诊区域的 30% 参与，其余医院转诊区域作为对照。自愿的肾脏护理选择模式提供了对全国肾脏病学实践开放的替代支付计划。为了帮助组织模型的实施，我们开发了作为蓝图来识别结构、流程和规范并生成干预概念的驱动程序图。我们专注于两个直接适用于肾脏病学实践的目标，并且是 ESRD 治疗选择和肾脏护理选择的激励结构的核心：（1 ) 提高家庭透析的利用率，以及 ( 2) 增加肾移植的数量。随着实施，几个反复出现的主题变得明显。需要来自不同背景的多个利益相关者。与初级保健提供者的沟通将有助于及时转诊、教育和共同管理。肾病学提供者（肾病专家、护理人员、透析机构等）必须领导实施。几乎每一步的患者参与都将有助于实现模型的目标。与联邦和州监管机构的宣传对于扩大家庭透析和移植访问至关重要。尽管这些模型有望改善许多患者的选择和结果，但我们必须警惕它们不会加剧现有的医疗保健差距或扩大已知的种族、社会经济或地理差距。