Options for Nursing Home Dialysis
The Problem
Patients who need dialysis—including those who do PD or home HD—may encounter a time when they need more care than they or their loved ones can provide at home. Some reasons why a patient may need nursing home care include changes in:
Ability to do activities of daily living such as personal hygiene, dressing/undressing, using the toilet, transferring from a bed to a chair, walking unassisted, eating
Health/medical needs like catheter care, intravenous injections, dialysis, or respiratory care (trach or mechanical ventilation)
Cognitive deficits and/or impairment in judgment due to such conditions as Alzheimer's, Parkinson’s or dementia
Behavior problems, such as wandering, getting lost, acting impulsively or aggressively as may happen with dementia
Nursing Home Care and Dialysis
In an interview for KidneyTalk in January, 2022, Alice Hellebrand of Dialyze Direct said 40,000 dialysis patients slept in a nursing home the night before, and 80,000 pass through a nursing home in any given year.1 A dialysis patient may have a hospital stay during which a need for rehab is identified. Sometimes inpatient rehab is provided where dialysis is offered. But, most of the time, rehab is needed on an outpatient basis. Those who need more intensive rehab than can be offered in the home may need to enter a skilled nursing facility (SNF) for a short stay to improve their physical functioning.
After rehab, a dialysis patient may be able to return home and resume their usual dialysis in a clinic or at home, with or without a care partner. When rehab cannot restore physical or mental functioning enough for a patient to go home, s/he may need long-term custodial or personal care. This type of care usually occurs in assisted living or a nursing facility (NF).
There may be limited choices of nursing homes when a patient needs dialysis. CMS allows nursing homes to refuse to admit a dialysis patient if the care needs are assessed as higher than their staff can provide. Low staff-to-patient ratios, lack of staff trained to do dialysis, concern about the level of care some patients might need and their special diets, and cost of transportation when dialysis is provided off-site are some reasons for refusal.
Medicaid can provide emergency or non-emergency medical transportation to dialysis and a patient may meet criteria for Medicare’s ambulance transportation benefit for dialysis, which is separately billable. But transportation can be costly for a patient who doesn’t qualify. During transport and while at an outpatient dialysis clinic for several hours, the patient may miss one or more meals and be unable to participate in rehab and social activities. Clinics often don’t allow patients to eat during dialysis, so they may have low blood sugar and poor labs that put them at risk of infection and hospitalization.
COVID increased the rates of kidney failure and the need for a capped or uncapped trach or ventilator support. Some patients with these complications may be so debilitated and depressed that they or their healthcare proxies may choose hospice and comfort care without dialysis. Others can be rehabilitated to their former level of functioning—including returning to dialysis in their own homes or getting training for home dialysis by a clinic that is Medicare approved for home training and support.
Finding a nursing home and a dialysis clinic that will treat the patient in any setting is even more challenging when a dialysis patient has a trach, especially an uncapped one. Concerns nursing homes have expressed include staff turnover and limited dialysis staffing, lack of training in suctioning a trach, and perceived infection risk. There is no evidence that a patient with a trach poses more infection risk in dialysis than a patient without a trach who coughs. If a dialysis patient who has Medicare is hospitalized, Part A expires after a stay of 150 days (90 days with the Part A deductible plus 60 lifetime reserve days with a daily copay). As that deadline approaches, hospitals scramble to find placements for these patients. Sometimes hospitals tell families that the closest nursing home or long-term acute care hospital to admit their loved one who needs dialysis is multiple states away.
Models for Dialysis for Nursing Facility Residents
Some companies provide dialysis in nursing homes. Dialyze Direct in 13 states and Concerto Renal Services in 11 states are Medicare-certified dialysis providers. Medicare and Medicaid pay them to provide home dialysis. They typically provide home HD, not PD.
A capable patient or care partner may be able to dialyze in a nursing home. If a nursing home can be found to admit a capable patient, s/he could do PD or home HD independently or with a trained care partner as long as the nursing home policies allow this. The home dialysis program would be responsible for that patient’s care.
Nursing home staff can be trained to do PD. When I worked in dialysis, my clinic did this. We didn’t have any home HD patients at the time. My clinic was paid for providing “home dialysis,” as nursing home residents were (and still are) considered home dialysis patients. Today, Medicare’s payment for SNF care is based on patient driven payment model (PDPM) that, from what I gather, uses a case mix adjuster to pay more for residents who are on dialysis, or have trachs or vents, especially those with depression and more limitations. Still, turnover among dialysis and nursing home staff makes this option less attractive to dialysis and nursing home providers than it seemed to be back then, so
PD patients especially may
have fewer options for nursing home care. One patient’s family
contacted me because they were moving to Florida. When I inquired, I was
told there are no nursing homes in Florida that admit PD
patients! It’s no wonder that PD patients end up switching to HD.
Per the USRDS 2022 Annual Data Report, in 2010, 31.4%
of PD patients switched to HD within 30 days of admission to a nursing
home, while 51.4% did so in 2020.2Dialysis RNs, LPNs/LVNs, or PCTs can dialyze nursing home residents on-site. DaVita and Fresenius have recognized this need and are partnering with nursing homes to offer this service. HD is usually done in a “den” setting with multiple patients treated at the same time. Medicare does not cover staff-assisted home dialysis, but a nursing home can save the cost of transportation and could be at a marketing advantage, especially for patients getting SNF care who qualify for extra payments under the PDPM model. They may be able to bill commercial payers who will pay for staff-assisted dialysis at a higher rate to cover the staff that does the dialysis.
A dialysis clinic might rent space in or next to a nursing home. Here, it can provide hemodialysis to nursing home residents only—or may treat nursing home residents and patients in the community. This would be billed as an in-center dialysis treatment.
Compliance with CMS Rules for Nursing Home Dialysis
On March 22, 2023, CMS published Guidance and Survey Process for Reviewing Home Dialysis Services in a Nursing Home REVISED, which was updated from the 2018 version. This guidance addresses many concerns and questions from the community and describes what to look for when surveying nursing homes and dialysis facilities that provide dialysis within a nursing home, i.e., a “skilled nursing facility” or a “nursing facility,”
The guidance covers 1). Ongoing collaboration of care between a dialysis facility and nursing home, 2). Adequate training for anyone that provides dialysis treatments, 3). Appropriate monitoring of the dialysis patient’s status before, during, and after the treatments, and 4). Ensuring a safe and sanitary environment for the treatments.
Some highlights include:
Dialysis clinics must be CMS-approved for home dialysis training and support in a nursing home. They are responsible for dialysis care; the nursing home is responsible for non-dialysis care.
Dialysis clinics must follow the ESRD Conditions for Coverage (dialysis regulations).
The person performing dialysis treatments must be trained, competent, and knowledgeable about all aspects of dialysis. An RN, LPN/LVN, certified nursing assistant, patient care technician, patient, or care partner can do the treatments.
There must be a written agreement between a certified dialysis facility and the nursing facility. The dialysis clinic must inform its state survey agency or accreditation organization of that agreement, which must describe the responsibilities of each party and their collaboration on care planning, including:
How the clinic and nursing home care team will communicate and collaborate on care
How the location where dialysis takes place is to be kept safe and sanitary
How the nursing home care team will be involved in developing and documenting the patient’s individualized care plan
How responsibilities for patient monitoring and care before, during and after dialysis will be laid out in a way to ensure state practice acts and limit are followed
The process for reviewing and monitoring the qualifications, training, competency, of anyone doing dialysis in a nursing home
How nursing home staff will be trained to address dialysis-related complications and provide emergency interventions, as needed
How dialysis equipment is to be maintained to ensure good working order.
Conclusion
Dialysis is a life-sustaining treatment, and some patients will need short or long-term nursing home care. This blog has presented some options for how we can care for dialysis patients who need nursing home care, even those with trachs, and suggests ways to do this while complying with CMS regulations and guidance.
Alice Hellebrand, Dialysis in a Skilled Nursing Facility, Renal Support Network’s KidneyTalk. January 10, 2022. https://www.rsnhope.org/kidneytalk/dialysis-in-a-skilled-nursing-facility/↩︎
United States Renal Data System. 2022 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2022. Figure 2.15. https://usrds-adr.niddk.nih.gov/2022/end-stage-renal-disease/2-home-dialysis↩︎
Comments
Krista Harding
Feb 15, 2024 5:43 PM
Beth Witten
Jul 17, 2024 10:39 PM
Pam Hines
Jul 17, 2024 7:16 PM
This blog is wonderful and so informative + good to hear of you after being with you in trainings in the distant past!
I am presenting next Monday at a statewide training for providers. Could I use your information and references from this blog?
Thank you,
Pam
Beth Witten
Jul 18, 2024 2:38 PM
Jessica Dollar
Aug 02, 2023 11:25 PM
Beth Witten
Aug 03, 2023 2:00 PM
When a dialysis patient is in a skilled nursing facility or nursing home, ambulance transportation to dialysis if medically justified can be billed to Part B. However, when ambulance transportation is not medically justified, dialysis-related transportation could be covered by Medicaid for eligible patients or communities that have fixed route transportation services may have low-cost Americans with Disabilities Act "paratransit services" for elderly or disabled patients. Dialysis social workers often know what services are available in their area for transportation. Here's an FAQ about paratransit services from the Federal Transportation Administration. https://www.transit.dot.gov/regulations-and-guidance/civil-rights-ada/frequently-asked-questions
Gina Bacome
Jan 07, 2024 1:48 AM
Beth Witten
Jul 17, 2024 10:03 PM
Laura Lee Dominguese
Jul 25, 2023 12:56 AM
Beth Witten
Aug 03, 2023 1:40 PM
Medicare also has a list of clinics that are certified to offer home dialysis that you can search by location and type of service for peritoneal dialysis.
https://www.medicare.gov/dialysisfacilitycompare/
Another option would be to contact the state survey agency for your state and ask to speak with an ESRD or nursing home surveyor. Because they have records of what services dialysis facilities and nursing homes offer, they should be able to tell you if peritoneal dialysis is offered in a nursing home in your area. Here's the list of state survey agencies by state: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/ContactInformation
Laura Lee Dominguese
Aug 07, 2023 5:15 AM