Getting the Most Out of Telehealth for Home Dialysis Patient

The current Coronavirus (COVID-19) pandemic is forcing unprecedented changes in daily life. Many vulnerable patients such as dialyzors and transplants are under “lockdown” or “shelter-in-place” orders, and the nephrology community has been forced to adapt quickly to a new reality.

Using telehealth visits in place of the usual face to face (F2F) monthly comprehensive visit can provide excellent patient care while limiting the risk of patient and staff exposure to COVID-19. However, even though telehealth has distinct advantages during this crisis for the vulnerable home dialysis population, many practical challenges remain.

It is clear, even after just a few months, that the expansion of telehealth has significantly strengthened health care delivery as more patients see telehealth as a safe and convenient option. It is hard to imagine ever retreating to the way things were before. "The genie's out of the bottle," said Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma.

Early in the pandemic, CMS convened a working group to determine best practices for the dialysis community and subsequently announced a number of new policies (waivers) to help physicians and hospitals during COVID-19. Home Dialyzors United had a place at that table and was able to contribute valuable insight into the needs of the home dialysis community. Dawn Edwards was part of a recent panel of experts on telehealth during the pandemic, sponsored by AAKP. Together, we have been advocating for patient awareness of the rights and responsibilities of home dialyzors especially with regard to clinic visits during these unprecedented times.

CARES Act Waiver Section 3705 now affords even greater benefits

One of the recent provisions in the CARES Act was that face-to-face (F2F) visits for home dialyzors could be conducted via telehealth. Under the Act, CMS had the authority to waive F2F visits until further notice, and on March 20 they issued such a Waiver. In other words, the CMS rule that you had to have a F2F once every 3 months has been suspended by Federal legislation and waiver during the pandemic:

SEC. 3705. TEMPORARY WAIVER OF REQUIREMENT FOR FACE-TO-FACE VISITS BETWEEN HOME DIALYSIS PATIENTS AND PHYSICIANS.

Section 1881(b)(3)(B) of the Social Security Act (42 U.S.C. 1395rr(b)(3)(B)) is amended— (iii) The Secretary may waive the provisions of clause (ii) during the emergency period described in section 1135(g)(1)(B).”.

Specifically the Cares Act authorized discretion in the enforcement of clinic visits and replace them with telehealth:

Due to the conditions presented by the PHE, we are also exercising enforcement

discretion on an interim basis to relax enforcement in connection with the requirements under section 1881(b)(3)(B) of the Act that certain visits be furnished without the use of telehealth for services furnished during the PHE. 

However, interpretation of this waiver has caused confusion among providers and patients:

• Most providers have complied and have patients using custom apps or Zoom.

• PD Patients obviously must go in for monthly blood draws, but the clinic visit can be via Telehealth. Even these blood draws may be suspended at the clinicians discretion.

• According to Section 3705 patients who are stable should be offered the Telehealth option for ALL clinic visits until further notice.

• A face to face visit is your choice during shelter in place, NOT a requirement.

• For clarification, payment is the same for an incenter visit or a telehealth visit.

• The ruling is for the convenience and safety of both staff and patients.

• Self-administering of anemia medications can be done at home – there is no CMS requirement that EPO and Venofer must be done by a nurse in clinic. If you feel capable to self-administer, insist that your clinic train you to do so and eliminate that additional contact risk.

• Contact your ESRD Network if you are being forced to visit the clinic unnecessarily during the pandemic, or if Telehealth is not being offered as an option.

There are some special challenges for PD patients. Clinics are using discretion in obtaining monthly blood samples. For stable patients with consistent PD prescriptions and erythropoietin stimulating agent (ESA) dose, monthly labs can be deferred to avoid requiring the patient to visit the clinic. For those requiring a monthly lab, clinics can arrange for an outpatient commercial laboratory or a home dialysis nurse may visit the patient at home. Medications and supplies that are typically dispensed by the dialysis unit, including ESAs, can be shipped to their homes. For patients who do not know how to self-administer ESA, nurses can use telehealth to teach self-administration. Intravenous iron infusions, however, will still require in person visits for PD patients.

Home hemodialysis (HHD) also presents some difficulties. Monthly laboratory testing, ESA and intravenous iron administration are less of an issue for HHD patients who are already trained to perform these tasks. For patients currently in-training, HHD prescriptions can be reduced to maintain adequacy and volume status but decrease the number of training days in unit to minimize the risk of exposure to COVID-19.

NOTE: During the recent meetings of the HHS working group, HDU brought up the fact that even if home dialyzors were exempt from F2F visits during the pandemic, they were still often required to visit the clinic to receive their prescribed dose of an ESA (epo) and/or iron (Venofer). HDU requested that this service be included in the waiver by stating that a nurse should be sent to the home if clinic policy will not allow the patient to self-administer these medications. Unfortunately, this policy could not be included in the waiver because there is no requirement restricting self-administration of these medications. They could not include a policy waiver for a policy that does notexist. This pandemic is a perfect opportunity for home dialyzors who are not self-administering their anemia medications to petition their clinic to do so.

Ultimately, telehealth has provided added convenience and safety for home dialyzors during these uncertain times of the Covid-19 pandemic:

• Eliminates unnecessary travel.

• Helps to limit exposure to infection.

• Reduces risk for contamination.

• Gives opportunity to dialogue with entire care team at once.

• Saves money and time.

• Prior to the pandemic, face to face clinic meetings were required by CMS once every 3 months…the remaining two clinic visits could be conducted via telehealth. Now all visits may be conducted via telehealth until further notice.

Like all things new, using telehealth may seem intimidating and unfamiliar at first. Here are a few telehealth tips to get started:

• Download the clinic telehealth app before your appointment.

• Familiarize yourself with the features of the app, if possible, prior to your scheduled appointment.

• Ask who will attend the telehealth visit and insist that all parties present introduce themselves – Social Worker, Dietitian, Nurse and Nephrologist.

• Choose a comfortable location, quiet and secure.

• Go to a good Wi-Fi area of the house.

• If you do not have good Wi-Fi or a smart device, request a telephone visit.

• Sign in early to troubleshoot technical issues.

• Get dressed! Comb your hair and brush your teeth
  .

• Write down any questions or concerns so you do not forget!

Make the most of your clinic time. Prepare a list of things to discuss with your team:

• Lab results

• Changes to medications

• Refills on medications

• Any necessary dietary changes

• Social Services or needs

• Any supplies needed

In conclusion, we need to ensure patient access to telehealth remains in place after the pandemic by repealing the "originating site" requirement, which forces patients to travel to certain healthcare facilities to receive telehealth services instead of allowing them to receive medical attention from the comfort of their home (as is permitted during the pandemic). We congratulate CMS for temporarily removing this requirement because of COVID-19, and Congress now needs to make it permanent.