Hi Liz, and welcome to Home Dialysis Central. Even though I don't run an HHD program, I wanted to respond to your post because of the approach you've described to patient "compliance," a word that I fully agree with you has a negative connotation.
At the Medical Education Institute (the non-profit organization that developed this site), we've spent the last dozen years doing research with people who have kidney disease--qualitative, quantitative, and even informal research. What we've learned from our own findings and the research of others is that when you're talking about a chronic disease--like kidney disease--compliance is not the issue. The notion of compliance arises out of an acute healthcare model, where temporarily "sick" people come to be "cured" and then take over their lives again. In an acute care model, healthcare professionals are the experts, and their job is to care for patients. Patients' job is to be passive and do as they're told ("comply").
In a chronic disease model, there is a recognition that the disease is not going to be cured, and that the patient is on his or her own far more of the time than he or she is supervised by a medical professional. The patient's job is not to comply, it is to self-manage, which includes following the treatment plan (instead of compliance), managing and reporting symptoms, and maintaining safety. The professional's job is not just to provide care, it is to prepare patients to self-manage and become their own experts.
So, the challenge I see in your approach is that it seems grounded in an acute model--you want to tell your patients the "expectations" and give them "three strikes or you're out." But if they're out, they're really in--in a center where they will be very, very unhappy, since they are used to being so independent that they seem to have left the sick role behind entirely and believe they're entirely in charge on their own! (The center will be unhappy to have them, too.)
It's ironic that many patients are so passive that it's difficult to get them involved in their care at all; while yours seem to have swung to the opposite extreme! The question is how to get back to a team approach, where both staff's input and that of the patient are both valued and both are required for a good outcome. Is there any chance that you could call a meeting of all of your home patients (or perhaps several small meetings) where you express a desire to get to know them and to work together to be sure they are getting the best care possible? It may defuse the situation and make it seem less accusatory if more than one patient is present when you explain that you need to have their flowsheets, their blood tests are important clues to their own well-being, that they may be charged (can you do this?) for appointments they miss, etc. I'm certainly concerned by missed treatments--it would be important to know whether these are really missed, done but not documented, or changed from one time of day or day of the week to provide the type of flexibility that HHD is supposed to offer--and what the adequacy numbers are for those patients...
If I were you, I'd ask each patient what his or her preferred call frequency is. Some might feel comforted that someone will check in with them and they will be able to ask questions, and some might feel that a weekly call is intrusive.
Anyway, I hope that some other folks who really do deal with these issues will also reply and tell you how they handled them!