What is On-Site Home Hemodialysis?
A Growing Opportunity
Prevalence of End-Stage Renal Disease (ESRD) in Skilled Nursing Facilities
Challenges with the current dialysis care model at Skilled Nursing Facilities have supported the growing movement towards a more patient-centric approach.
Clinical Challenges
Dialysis patients that receive traditional off-site in-center hemodialysis treatments may struggle with hemodynamic or cardiovascular instability associated with longer, conventional hemodialysis treatments.
Conventional hemodialysis in-center is also associated with longer recovery times and lower energy levels resulting in patients missing meals, rehabilitation, and social activities11
Economic Challenges
Patients being treated in a dialysis center undergo the stresses of transportation 3 times a week to their clinic.
- May result in missed or delayed treatments as a result of breakdowns in the coordination of care, which could potentially impact the cost of care and resource planning.
Operational Challenges
Staffing and scheduling for both dialysis providers and SNFs are already complex due to the care these patients require. By factoring in transportation to the mix, it becomes a daunting three-way communication challenge to organize and staff teams effectively.
- Patients may arrive late or miss treatments, potentially resulting in lost revenue for dialysis providers.
- Delays or schedule changes could result in confusion around meals or medications.
On-Site HHD - A Care Model for Success
Benefits of On-Site HHD
Benefits of On-Site Home Hemodialysis (HHD)
Patients performing more frequent HHD on-site in a SNF have shown improvements in both survival and hospitalizations.4 In addition, more frequent hemodialysis in the general population is associated with:
- Less risk of cardiovascular hospitalizations5
- Improved post-dialysis recovery time6
- More energy & vitality7
- Reduced antihypertensive medications8
- Improved survival9
Providing On-Site HHD in a SNF environment can offer dialysis providers an opportunity to increase home patient census by shifting in-center hemodialysis patients to Home patients in a SNF.
Effective Care Partnerships
Effective Care Partnerships3
Effective on-site home hemodialysis programs rely on a strong partnership between dialysis providers and Skilled Nursing Facilities to manage everything from staff training, to equipment and care plans.
Dialysis Providers
- Oversight of the home dialysis program (Med Director, Nurse Manager, etc.)
- Manage dialysis equipment and supplies
- Provide medications and labs associated with dialysis
- Handle billing and reimbursement associated with dialysis treatments
Skilled Nursing Facilities
- Identify treatment space for dialysis
- Cover expenses for basic utilities (water and electricity)
- Determine dedicated secure areas for equipment, supplies, and medications
- Cover labor costs for staff-assisted dialysis (care-giver fee)
- Receive and handle supplies delivered by courier
Shared:
- Policies and procedures – e.g. emergency planning, infection control
- Coordinated patient care plans
- Caregiver and staffing
CMS requires a formal coordination of care agreement between the SNF and the dialysis provider when ESRD patients are residents in the SNF.
Considerations for
Implementing a Program
Standard On-Site Set-Up
NxStage is the practical dialysis solution with more than 11,000 worldwide patients in the home environment.10
NxStage provides individualized treatment options to meet the clinical needs of patients, which additionally may allow patients to maintain rehabilitation, medication, meal and activity schedules.
Designed for Success
NxStage offers the following advantages over traditional equipment in a SNF setting, including:
- Minimizes requirements for plumbing and electrical alterations
- Eliminates chemical disinfection cycles
- Minimal changes required to existing plumbing and electrical wiring
- Eliminates maintenance of RO water treatment
- Lowers utility costs12,13
- Smaller treatment space
Resource Center
Despite the health benefits that more frequent home hemodialysis may provide to those with chronic kidney disease, this form of therapy is not for everyone.
The reported benefits of home hemodialysis may not be experienced by all patients.
The NxStage System One is a prescription device and, like all medical devices, involves some risks. The risks associated with hemodialysis treatments in any environment include, but are not limited to, high blood pressure, fluid overload, low blood pressure, heart-related issues, and vascular access complications. The medical devices used in hemodialysis therapies may add additional risks including air entering the bloodstream, and blood loss due to clotting or accidental disconnection of the blood tubing set. When vascular access is exposed to more frequent use, infection of the site, and other access related complications may also be potential risks. Patients should consult with their doctor to understand the risks and responsibilities of home and/or more frequent hemodialysis using the NxStage System One.
Patients and providers are encouraged to contact their state regulators to discuss state-specific regulations that may impact dialysis in the Skilled Nursing Facility setting.
References:
- 2019 USRDS Annual Data Report Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2015.
- DataDialysis.org. FY2017 Dialysis Facility Report Data. 3. Yang A, Lee WY, Hocking K, Xelay Acumen, Inc., Affiliated Dialysis. Survival comparison of daily home hemodialysis vs conventional dialysis in the nursing home setting. Nephrology News & Issues. February 17, 2015.
- Data on File. NxStage Medical, Inc. Health Advances Interviews. March 2020. Based on interviews with 9 facilities.
- Weinhandl E, Hocking K, Markovich S, Vavrinchik S, Collins A. Increased Hemodialysis Frequency is Associated With Improved Clinical Outcomes Among Patients in Skilled Nursing Facilities. Abstract presented at ASN 2018.
- Weinhandl ED, Nieman KM, Gilbertson DT, Collins AJ. Hospitalization in daily home hemodialysis and matched thrice-weekly in-center hemodialysis patients. Am J Kidney Dis., 2015;65(1):98-108.
- Jaber BL, Lee Y, Collins AJ, et al. Effect of daily hemodialysis on depressive symptoms and post dialysis recovery time; interim report from the FREEDOM (Following Rehabilitation, Economics and Everyday-Dialysis Outcome Measurements) Study. Am J Kidney Dis. 2010;56(3);531-539.
- Finkelstein FO, Schiller B, Daoul R, et al. At-home short daily hemodialysis improves the long-term health-related quality of life. Kidney Int. 2012;82(5);561-569.
- FHN Trial Group. In-center hemodialysis six times per week versus three times per week. N Engl J Med. 2010;363(24);2287-2300.
- Weinhandl ED, Liu J, Gilbertson DT, Ameson TJ, Collins AJ. Survival in daily home hemodialysis and matched thrice-weekly in-center hemodialysis patients. J Am Soc Nephrol. 2012;23(5);895-904.dol:10.1681/ASN.2011080761.
- Data on file. NxStage Medical, Inc. Healthcare Advances Interviews. May 2013. Based on interviews with 5 facilities.
- Data on File. NxStage Medical, Inc. July 2020.
- In-center water calculations based on 500 mL/min DFR, 220 minute treatment, 109 L of dialysate per treatment, 3 treatments per week. This simulation uses a 3:1 ratio for RO systems
- Home hemodialysis calculations based on 190 mL/min DFR, 30 L, 158 minute treatment, 30L of dialysate per treatment, 5 treatments per week. This simulation uses a 1:1 ratio for DI systems
