Home Dialysis “Support Services”: Is It an Inspection or a Visit?

This blog post was made by Beth Witten, MSW, ACSW, LSCSW on February 21st, 2019.
Home Dialysis “Support Services”: Is It an Inspection or a Visit?

I was asked to write a blog about home inspections. This was not a term I’d ever heard before, but I realized that term is sometimes used on social media to describe home visits for home patients. I asked a couple of home training nurses I know if they’d ever heard home visits described as home inspections and neither had heard or used that term. One told me that hearing that term opened her eyes to how a patient might feel when she says she needs to do a home visit.

Some posts from members of the Home Dialysis Central Facebook group indicate that they welcome staff visiting their homes and have seen benefits of the visit.

  • I did HHD for a year and a half before I got my transplant. I had a good relationship with my nurse. I lived right down the street from the center and he would often stop by on his way home. I never felt it was like an inspection. Everything was always in order and we followed instructions and cleaning routine to the "T". When I was on PD that nurse came several. Same thing. Always nice visits.”

  • Our home visits have never been conducted as an "Inspection " usually just the nurse stopping by with something.”

  • I think people become more comfortable at home and may skip important steps. So, it’s good to have that reminder and training every so often.”

Some had a home visit for a specific purpose:

  • Our center comes to check the PAK.”

  • I got a few catheter infections back to back and the nurse made a home visit.”

A response to some posts about the home visit providing an opportunity for continuing education said this:

  • I have had 2 visits since the initial one when I started at home almost 5 years ago. One home visit was done by a tech, last one by an RN. Neither observed me preparing or doing any part of treatment. They just wanted to see the room where I was set up to do treatment and where I kept my supplies. I understand the need to make sure the home is not dilapidated and am sure there have been some horror stories, but it doesn't help identify bad practices or provide continuing education. At least the way my visits were conducted doesn't.”

It's quite apparent that patients need to be better informed about the purpose of home visits to counter the concern that a visit is an “inspection” intended to deny people home dialysis.

It’s important to understand the regulations with which dialysis clinics have to comply. The ESRD Conditions for Coverage only allows clinics that the State survey agency has surveyed and certified for home peritoneal and/or home hemodialysis to provide services to home dialysis patients. Federal regulations require the interdisciplinary team (doctor, nurse, dietitian, and social worker) to provide services to home patients that are at least equivalent to those they provide to in-center patients. Clinics that provide home dialysis must comply with all other applicable federal, state and local laws and regulations.

The ESRD regulations have specific requirements for training, monitoring, and support. To help patients understand the rationale for dialysis staff making home visits, there is a requirement at 42 CFR 494.100(c)(1)(i), under “support services” for Periodic monitoring of the patient’s home adaptation, including visits to the patient’s home by facility personnel in accordance with the patient’s plan of care.”

The Interpretive Guidance for this standard in the regulation states:

“To assess a patient’s home dialysis environment, a home visit should be conducted at the initiation of home therapy and whenever a problem is identified with either patient health or equipment that could be related to treatment at home. Periodic routine replacement of equipment would not necessarily require a home visit be schedule. The interdisciplinary team my designate the most appropriate staff member(s) to make the home visit(s).

Documentation of home visits should be included in the medical record. The number, timing, and frequency of home visits should be based on individual patient need as indicated in the patient’s plan of care. Distance from the facility or concerns about staff safety should not preclude home visits. If a patient refuses a home visit, the interdisciplinary team must evaluation his/her refusal and the potential impact it may have on achieving the goals identified in the patient’s plan of care as well as discuss alternative ways to assure the patient’s health and safety at home.”

I asked a couple of home training nurses I know the following questions about home visits.

Who, if anyone (nurse, biomed tech, other) makes a home visit prior to training?

  • RN and often the social worker, biomed if the patient is going to do HHD, so he can help them with questions regarding water source and training.”

  • RN and tech, social worker if there are issues like bedbugs to find resources to correct that.”

What is the reason for the visit and what are you looking for?

  • Initially, I do a home visit to meet the patient to go over options and what’s needed based on the treatment the patient wants to do. For example, for HD, I look for access to power, drain, and what water treatment is needed. For PD, I look at power for the cycler, how clean the area is where they plan to do PD, whether there are vents or fans that need to be turned off when doing an exchange, whether there is room to store supplies. I look at how to work around barriers like scheduling supply deliveries monthly or every 2 weeks if space is limited.”

  • For PD, I sometimes visit the patient who is considering home therapy before they see the surgeon for PD catheter placement. However, usually I see them after that visit when a PD catheter is schedule. For HHD, I can train them on self-cannulation while they’re in-center as that takes a big “chunk” of the energy and angst out of training if that’s already learned. While I’m training them on that, I explain about the home visit, to see if there’s room for the boxes/machine and discuss where’s the best place—to see if they have storage space enough for a month of supplies vs. 2 weeks of supplies.”

Do you do any training in a patient’s home?

  • “Taking dialysis home is like taking a new baby home from the hospital. I do the 5th day of PD training in a patient’s home. With home HD, I do the last week of training in the patient’s home.”

  • “My method of operation is to do PD training at the center then 1-2 of the last trainings at their home. For HHD, the last week of training, I like to come to their home and teach/help them as they begin doing their therapy at home—and it isn’t a “week” hard and fast; it can be more or less depending on their need.”

Do you do a home visit at a set frequently after training is completed and what are you looking for?

  • “Yearly has been (company) policy, but they just upped it to an initial visit, right after completion of training to observe the patient doing their treatment preferably, and then within 30 days I make another visit. We’re looking to see that the patient isn’t struggling or having questions or has strayed from what they were taught.”

  • “I visit annually or more often if with PD there is peritonitis so I can do a root cause analysis. I have a checklist and watch what the patient does to make suggestions if I see areas of concern. I look for frequent touch points and come back once a week for a month and ask the patient to demo the manual PD exchanges or the cycler.”

When might a clinic/corporation deny a patient home HD or PD based on a home visit?

  • “These are just examples: excessive amount of animals in the home, nonfunctioning electricity (or lack of 3-prong plug-in) or non-functioning plumbing (e.g., 5-gallon bucket that the sink drains into), evidence of poor hygiene/cleanliness—excessive pet hair, piles of trash not taken out, piles of unwashed dishes, windows without screens that are open and gnats and flies. I haven’t denied them—but I talk with them about whether they’re willing to correct these things, discuss why it’s important and see if they want to schedule a re-visit.”

  • “If I have concerns, I want to know how willing the patient is to do something different to avoid infection or other problems. I had a PD patient once who had a dirt floor and no running water. He never got peritonitis. If I have concerns, I take them back to the rest of the team—MD, dietitian, social worker—and ask them to try to think of ways to overcome those concerns.”

Admittedly the sample of nurses I asked was small and it’s possible that other home training programs and staff operate differently. However, in my experience, a home dialysis visit can be a good way for the patient to get to know the nurse or other staff who comes to their home better, and it gives the dialysis staff visitor the opportunity to see patients in their home where they may be more comfortable and less stressed than in the clinic. My best friend is a former home training nurse. We met when we worked together at the University of Kansas Medical Center in the late 1970s and early 1980s. Her goal was to do an annual home visit to patients. In those days, there weren’t many outpatient clinics in Kansas, and she had patients several hours away. She told me how one of her patients invited her to eat a meal with the family, how welcome that made her feel, and how much that helped her get to know that individual as a person—and not just a dialysis patient.

I hope that those who read this blog will help patients see that contrary to a “white glove inspection,” a home visit can be a way to assure that your patients have a successful home dialysis experience and that in most cases concerns that are identified during the home visit can be overcome with help from the team and willingness to make adjustments on everyone’s part. Maybe if you provide this education and show your patients respect for their knowledge of their bodies and their treatment, you’ll be invited to a meal like my friend.

Comments

  • Peter Laird, MD

    Feb 22, 2019 1:53 PM

    My home visits during the first 8 1/2 years of home dialysis were pretty cursory and non-intrusive.

    My last 6 months before being involuntarily discharged from my home program were completely invasive and truly unnecessary to the point that my new nurse wanted to watch me set up the machine, program it, and cannulate and initiate a treatment with her watching. 3 weeks before this planned visit, two nurses came to my house to observe me collect water samples from my RO and Baby K.

    Then she did not like my method of collecting dialysate and told me to change my procedure even though I was doing it exactly as taught and the same exact way a tech drew it two months later.

    So, while in theory home visits should not be intrusive, they can be when you have a team set on removing you from your program.

    Reply to this Comment

    * All fields are required.

    1. Your email will not be displayed publicly
    • Beth Witten

      Aug 3, 2019 11:41 AM

      I failed to respond to your message timely. Seeing it again today after Curtis responded to you, I wonder what would have happened if you had asked for a copy of the procedures for doing those actions to review them to see if anything was changed from how you were trained many years before. Could the new nurse's request to observe you performing those actions have been to make sure you were doing your treatment following the up-to-date procedures? If this occurred after the 2008 regulations took effect, I don't see how the home visit alone should have led to an involuntary discharge allowed under those regulations. Did you file a grievance within the dialysis company and if that didn't resolve the dispute, with the ESRD Network and/or the State Survey Agency? I believe you changed clinics and are still on home dialysis. How have your home visits been since the change occurred?

      Reply to this Comment

      * All fields are required.

      1. Your email will not be displayed publicly
    • Curls

      Aug 3, 2019 7:29 AM

      Peter, why would they want you off the program after 8 1/2 years?

      Reply to this Comment

      * All fields are required.

      1. Your email will not be displayed publicly
  • Tom Nord

    Feb 22, 2019 11:12 AM

    As training for HHD is completed, one of my clinic's policies was to have your training RN present at your first home treatment. I have since refused visits that I did not see were necessary. I believe my HHD home 'clinic' is as aseptic to even a higher standard than theirs. Mine is mine only and not shared with others, so the spread of germs and possible BSI's are much more preventable. Since my caregiver and wife passed away and I am solo I believe it inappropiate unless I have my own representative present. Otherwise I would welcome any observers as long as they are trained in aseptic technique. This is helpful information to all of us involved in the modality. Thank You

    Reply to this Comment

    * All fields are required.

    1. Your email will not be displayed publicly
  • John Agar

    Feb 21, 2019 3:02 PM

    Beth ... a very important blog.

    Understanding each patient, how their home works - for them - and thus how home dialysis will best fit each individual patient/home circumstance is a crucial learning experience for home training staff. It is never conducted as, nor should be seen as, an ‘inspection’. But as home trainers want the home dialysis they train their patients for to be a successful, positive experience, they must be able to work with, advise, and understand the practical dynamics of each individual home to ensure the best outcomes.

    A well balanced and vital blog. Well done.

    Reply to this Comment

    * All fields are required.

    1. Your email will not be displayed publicly
Leave a New Comment

* All fields are required.

  1. Your email will not be displayed publicly