Training and Treating Home Dialysis Patients with Daytime Responsibilities

Dialysis Clinic Operating Hours

Patients may start dialysis with daytime obligations or may have a life change that adds daytime responsibilities. What do you know about patients’ lives away from dialysis and how those lives might affect their dialysis—or how dialysis may impact their lives and other responsibilities? They may have a full or part-time job, a child, an elderly adult, a person with a disability that they care for, or something you didn’t consider. These patients need to be informed and encouraged to consider home dialysis. The education and encouragement you provide may help them to see this option as attractive and doable.

Challenges for Home Dialysis Patients

How can we help these people when most dialysis clinics operate only during daytime hours? Both in-center dialysis patients and those who need home training and have daytime responsibilities may need more flexibility. It may not be a game changer when a working patient needs to do a day or two of respite during a weather emergency, a home machine issue, or a brief care partner break. However, daytime dialysis or home training that is offered only on weekdays can be very challenging for patients who must be a clinic for weeks at a time. This can happen when a PD patient is recovering from peritonitis and has to let their belly rest, or a patient needs weeks of training/re-training. Having no other option could jeopardize a patient’s job and livelihood, including job-based insurance. What options might clinics and patients have? Some suggestions include:

• Screen patients with jobs or other daytime obligations for PD.

• Offer solo PD, daily home HD, or nocturnal home HD to a patient who demonstrates the ability to perform all dialysis tasks safely without help and has an acceptable emergency plan.

• Change a home training nurse schedule to train patients and care partners on evenings and/or weekends.

• Make respite care available at a clinic that offers a shift starting after 5 p.m. (preferably in the home training area), nocturnal in-center HD—or in the home, with a nurse visit.

Screening Patients with Daytime Obligations for PD

In the U.S., in-center HD is the default first treatment for most patients. Some countries follow a “PD-First” model:

• PD-First has been the policy in Hong Kong since 1985; more than 35 years. The U.S. secretary of the Department of Health & Human Services recognized this program In 2021. In Hong Kong, more than 73% of dialysis patients use PD.¹

• In India, PD as a first treatment was found to improve quality adjusted life years (QALY) and save money.²

• In Italy, PD as a first treatment improved patient survival, quality of life, preserved kidney function, and reduced costs.³

In 2011, an article discussed a rationale for PD as a first modality, pointing to a survival advantage, lower infection rate for PD vs. HD, adequacy similar to standard in-center HD, flexible scheduling, short-term treatment for those awaiting transplant, preservation of residual kidney function, lower cost, and higher patient satisfaction with care. The article suggested solutions to address reasons why PD patients transfer to HD.⁴

Screening Patients for Solo Home HD or Home Nocturnal HD Without a Partner

Most clinics require home HD patients to have a care partner. The patient may do all steps in the treatment process with his/her care partner only expected to help if s/he needs an extra pair of hands or to handle an emergency. In this case, a care partner should not need to be present for every training day. Fewer training days can help a care partner who has daytime responsibilities help a friend or loved one while maintaining a life away from dialysis.

A home training nurse who is treating a home HD patient facing any of the situations listed above should determine if a patient is interested in doing solo HD during the day or nocturnal HD. If so, the nurse should assure that the patient can do all dialysis tasks independently and safely. S/he should confirm that the patient knows how to handle most emergencies without onsite help and ask the patient to describe his/her emergency plan to assure that it’s comprehensive and feasible. Patients with or without partners may have questions during treatment or may need help troubleshooting problems.

Training Patients/Care Partners Outside Normal Operating Hours

Success of a home dialysis program is dependent on an enthusiastic and knowledgeable team that includes a nephrologist, one or more nurses, and the dietitian and social worker. One article describes its program as having an RN to PD patient ratio of 1:20 and 1:12 for home HD.⁵ Dialysis clinics are required by regulation have someone available to advise home patients when they need help 24 hours a day, 7 days a week. This can be challenging when a dialysis clinic has a small home dialysis program with a single home training nurse—especially if that nurse was promised a Monday - Friday 8-5 schedule. When clinic management and nurses are open to working with patients who need training or support outside those hours, it can help to expand the program and retain patients.

Today PD and home HD machines allow remote monitoring using wireless encrypted data sharing, which makes it easier for a home training nurse to see treatment data and troubleshoot problems no matter when a patient does dialysis. Fresenius started using remote treatment monitoring (RTM) for PD in 2016, and found that frequent users had fewer and shorter hospital stays and lower rates of technique failure during follow-up.⁶ The NxStage Nx2Me app that clinics can provide for home HD patients was found to increase the home HD patient graduation rate and reduce technique failure and home dialysis attrition.⁷

Accommodating Home Dialysis Patients Who Need Respite Care

When a patient’s care partner is ill, is away for a personal reason, needs a break, or quits, it’s important to figure out how to help home patients do their treatments. When a clinic is approved for in-center and home dialysis, the patient may be able to get backup dialysis in-center at their usual clinic. But when a clinic is full or only offers home dialysis training and support, how does their patient get respite care? By regulation, every clinic that treats home dialysis patients must have an agreement from another clinic where they can transfer a patient for back-up dialysis. However, few dialysis clinics offer dialysis shifts starting after 5 p.m. or in-center nocturnal dialysis. The Medicare website lists the dialysis clinics that have shifts starting after 5 p.m. The database defaults to 25 miles but there is a down arrow to select from 5 miles to 200 miles from a location. That website does not say which clinics offer in-center nocturnal dialysis. Dialysis Units in the USA says of 7,749 dialysis clinics, only 1,251 (16%) offer shifts starting after 5 p.m. and just 351 (4.5%) offer nocturnal dialysis in the clinic.

More importantly, home patients and their care partners often do not want in-center respite, which may be far less dialysis than they are used to. Combining a home visit with a respite treatment or two can allow a real break for a care partner.

Conclusion

The ESRD Treatment Choices (ETC) model offers payment incentives for dialysis clinics that increase their percentage of home dialysis patients. Many patients choose home dialysis because they have home responsibilities that make it difficult to do in-center dialysis and others want to work. To help to grow home dialysis programs, we need to make it as easy as possible for these patients to train for home dialysis and succeed at home. We can do this by offering home training, clinic visits, and respite on days and at times that accommodate patients’ other responsibilities. To accomplish this, it is important for dialysis providers to:

• Support home training RNs to schedule time to accommodate patients’ training and support needs.

• Allow home training to be done in patients’ homes if needed to get a patient home.

• Allow clinic visits through telehealth for two visits per quarter for stable home patients.

• Support home patients who have questions/concerns by assuring that those who are supposed to provide after-hours support services are sufficiently knowledgeable about all home dialysis options and equipment used by patients at clinics they support.

• Ask patients what they need and make reasonable efforts to meet their needs.

Making these efforts could help to grow home programs and improve patient satisfaction and patient retention on home dialysis.