THE ACCESS — AN ATLAS OF THE U.S. DIALYSIS SYSTEMPLATE I — FIRST STATE — 07|2026

The Crossroads

A DRAWN MAP · WHAT HAPPENS TO A PERSON

The person’s own map: the planned start or the crash start nobody planned, the preemptive transplant that bypasses the chair entirely, the modality crossroads where the education window either happened or didn’t, the switching loops between center and home, and the exits. The framed region at the top is the prologue: everything that happens before the chronic outpatient map begins.

HOW TO READ · BOX = A STATE A PERSON CAN BE IN · ARROW = THE MOVE BETWEEN THEM · HAIRLINE REGION = THE PROLOGUE — BEFORE THE MAP BEGINS · HAIRLINE BOX = MARGIN NOTE
AN ATLAS OF THE U.S. DIALYSIS SYSTEMWIDE GRAMMAR — STATE MACHINEPLATE I
The CrossroadsFIRST STATE · ED. 001 · 07|2026
UNDIAGNOSED CKD KNOWN CKD NEPHROLOGY MONITORING AKI — FUNCTION RECOVERED CRASH START HOSPITAL ACUTE DIALYSIS PLANNED START OUTPATIENT TRANSITION ESRD — MODALITY SELECTION IDT ASSESSMENT + PATIENT PREFERENCE IN-CENTER HD 3X/WEEK CADENCE HOME HD 5–7X/WK SHORT DAILY NOCTURNAL 3–7 NIGHTS/WK PD — PERITONEAL CAPD CCPD CONSERVATIVE CARE MEDICAL MGMT, NO DIALYSIS TRANSPLANT FUNCTIONING GRAFT WITHDRAWAL HOSPICE / PALLIATIVE DEATH screening / PCP referral symptomatic ED presentation rapid progression / lost to follow-up staged eGFR decline, access placed in advance renal function returns nephrology follow-up (LOOP) preemptive transplant — bypasses dialysis entirely no recovery at ~90 days (2728 filed, Medicare entitlement) home training care partner burnout / clinical instability later PD conversion peritonitis, membrane failure, catheter loss waitlist / living donor patient decision graft failure — the route returns AN ATLAS OF THE U.S. DIALYSIS SYSTEM · PLATE IV — THE CROSSROADS, COMPOSED PLATE IV TERRA INCOGNITA — BEFORE THE MAP I — THE PROLOGUE · BEFORE THE MAP BEGINS II — THE CROSSROADS III — THE EXITS THE ~90-DAY BOUNDARY · FORM CMS-2728 FILED · MEDICARE ENTITLEMENT BEGINS · THE FEDERAL MAP OPENS † ‡ § † EDUCATION WINDOW (optimal) Modality education, access planning, transplant eval, KDE benefit (MIPPA) ‡ EDUCATION GAP No modality education occurred. Default pathway = in-center HD via CVC. Highest mortality cohort. § EDUCATION WINDOW (late) In-facility modality education — a patient right, 42 CFR 494.70(a)(7); the IDT home-plan-or-rationale duty sits at 494.90 — but choice architecture already constrained by start type KEY DRAWN, NOT BOXED MAJOR ROUTE MINOR ROUTE THE 90-DAY BOUNDARY — CYANOTYPE CROSSING CORRIDOR — SOLID INK THE ROUTE — N=1 · VENOUS AT CROSSINGS ENTRY / EXIT † MARGIN NOTE ANCHOR THE ACCESS — AN ATLAS OF THE U.S. DIALYSIS SYSTEM THE CROSSROADS The patient journey, pressed as a map. PLATE IV · THE TWO WALKS · ED. 001 · 07|2026 SRC: RIG/THE-CROSSROADS.RIG.JSON LEDGER: PATIENT-JOURNEY-V1-VERIFICATION.MD
KEY
A STATE — WHERE A PERSON IS
A TRANSITION — HOW THEY MOVE
THE PROLOGUE — BEFORE THE MAP
MARGIN NOTE
THE 90-DAY BOUNDARY — THE SYSTEM'S FIELD
THE ACCESS · 07|2026
ED. 001 · DRAWN MAP SRC: 42 CFR 494.70(a)(7) / 494.90 · KDOQI · CMS-2728/2746 · LAST VERIFIED 2026-07-08
PLATE I · FIRST STATE DRAWN UNDER THE AUTHOR’S DIRECTION · VERIFIED AGAINST THE ATLAS DATASET
AWAITING THE AUTHOR’S PASS PLATE II
THE ATLAS CONTINUES PLATE II — THE BORDER NEXT →