Home Hemodialysis Training Re-Imagined
I have been a nurse for 34 years, and have worked in the dialysis field for the last 13 years, and my "sweet spot" is, without a doubt, home hemodialysis. I began my career in nephrology 13 years ago after my husband was diagnosed with polycystic kidney disease (PKD), and I went to work for his nephrologist, Dr. James Smelser, as an in-center dialysis staff nurse, then later as a hospital dialysis specialist. My job there included doing acute dialysis in ICU units as well as PD and plasmapheresis.
While working in the hospital setting, I subscribed to NN&I and Dialysis and Transplantation in addition to being an ANNA member. It was in reading these 3 journals from cover to cover that I learned about the overwhelming benefits of NxStage and HHD. After urging Dr. Smelser for 3 years to consider using NxStage, he finally agreed and asked me to become his first HHD nurse. I trained 30 HHD patients (using the NxStage System One) in northern Alabama and southern Tennessee and was the only HHD nurse within a 100 mile radius for quite a while. I became addicted to seeing how much better each patient felt after just 1 week on NxStage. For instance, Dr. Smelser and I had to establish a protocol for BP med removal which amazingly began in week 1 of training! After seeing firsthand how lives are transformed by this modality, I consider HHD "the sunny side" of dialysis.
For more than 4 years, I worked for NxStage, training new home therapy nurses in Mississippi, Tennessee, and Alabama. Although I desperately miss training patients myself, I know I can help more patients get home on HHD if, while training a new nurse, I can motivate and inspire him or her to catch the vision! As a NxStage clinical educator, you could find me in a home therapy clinic somewhere in Mississippi, Tennessee, or Alabama training an HHD trainer. I saw the good, the bad and the ugly of all dialysis companies in my area. There are many frustrating hindrances and road blocks to this modality across every dialysis company.
I have been saddened to learn that not all nephrologists are home therapy champions like Dr. Smelser. It is my steadfast belief that patients, regardless of race or financial status should be allowed the benefits of this modality, and it should not hinge on whether or not the patient has commercial insurance or whether or not the nephrologist makes more money if all his in-center chairs are filled. These patients are over a barrel. They dialyze or die. God forbid anyone take advantage of that!
Across the Board, HHD Training Needs a Complete Overhaul
HHD is not PD and can't be fit into that box. PD is very important—and so is HHD. I daresay you can grow a booming HHD program by just transitioning your failed PD patients instead of sending them back in-center. Why isn’t this being done more? Because HHD trainers are few and far between, due to the overwhelming burden dialysis companies place on them. If your home program doesn’t have a HHD trainer, your failing PD patients are simply out of luck and placed back in-center.
I spent the vast majority of my time training a newly hired HHD trainer at an already established home clinic because the previous nurse got overwhelmed and frustrated and moved on to another job. These nurses are training lay people to access their blood and operate a life sustaining device in their homes! They need to be able to hunker down and focus on what they are doing without interruption. So many nurses have expressed to me that they get an impending doom feeling in the pit of their stomachs trying to figure out when they are going to find time to do all the mundane yet very important other stuff they have to complete after training a patient—without working overtime. Almost all HHD trainers are also required to train and maintain PD patients as well as all of the HHD patients who are already home. It is no wonder home therapy nurses avoid HHD training like the plague!
It doesn’t take a rocket scientist to figure out that you will never grow your HHD program if you can't keep your staff. Action has to be taken to make the HHD trainer position a desirable one. I happen to have the audacity to declare that until companies are willing to remove the HHD trainer from the nurse/patient ratio, growth will be extremely difficult. I wonder how much money is totally wasted by these dialysis companies staying in the same rut? They spend a lot of money to get new nurses through orientation and training, only to lose them a few months later due to burnout. This money could instead be spent on hiring a nurse to maintain the current home patients. This nurse could handle all clinic visits, calls, med changes, care plans, iron infusions and other hosts of interruptions that totally bog down an HHD trainer. The trainer could then be free to train like the wind! If a home training nurse is freed up to focus only on training, s/he will refine training skills and be able to head off problems, adapt training methods to individual patient’s needs, and become an overall expert trainer in a short amount of time. The patient will have a superior training experience and will be better trained. The HHD trainer will be blessed to experience the joy of seeing patients blossom. The nurse’s job will be rewarding, exhilarating and best of all…desirable. Staff retention as well as patient retention will be the win/win result.
Thankfully, the new CMS regulations are recently providing much better financial support for home clinics who dare train HHD. I truly feel that in the future it is the HHD program that is going to set home therapy clinics apart. The elite clinics will have a booming HHD program along with their PD programs so patients can STAY at home.
Because I have a front row seat inside so many home dialysis clinics on a weekly basis, and have been confronted with so many obstacles to HHD success, I am determined to devote my life work to finding solutions to each and every one. I am a patient advocate to the bone. I want to make the biggest impact I can for dialysis patients before I die. I won’t give up. Some people are God’s hands, some are His feet. I want to be His Kidneys!