Editor’s Note: The author will be giving a presentation on the topic of this article at the National Kidney Foundation 2012 Spring Clinical Meetings in National Harbor, Md., in May.
My starting point for this article is that you are impressed with the improvement in patient quality of life and cardiovascular outcomes of more frequent home hemodialysis (HD) and you recognize that many, but not all, of your patients will greatly benefit from this modality.
As you develop and grow a home HD program, not only will you have wonderful successes, but there will also be challenges and disappointments. To stay on course the program needs a philosophy and, as trite as it might be, a mission statement.
Our program keeps it very simple: “It’s all about the patient.” That is, we practice “patient-centric” medicine and try to incorporate the patient’s vantage point in every aspect of the program. Every project, miscue, and opportunity for improvement in the process of setting up a home program will turn into a success if the entire home HD team focuses on the patient’s needs (and not necessarily ours).
There are three major components of a home HD program: the people, the physical infrastructure, and the policies and procedures by which the clinic is run. For certain, the people are most important and patients are paramount because without patients there is no program (Table 1). A dialysis facility needs to project census prior to developing space and hiring staff.
The last thing one should do is build a space you will outgrow within a year, or have to mothball because of inadequate utilization. You need to set a goal. Based on some studies, personal experience, and discussions with colleagues, I believe a realistic number is 8%-10% of dialysis patients will embrace home HD. That number will vary according to demographics, and some practices will have higher utilization. Do not think that a beautiful home and a college education is a requirement.
We have single mothers with barely high school educations who succeed tremendously on home HD. There are several sources of patients. The largest is probably transfers from in-center dialysis, but CKD education programs, both outpatient and inpatient, will help attract patients.
To recruit patients from your in-center program, consider “lobby days” where patients can receive educational materials and see the home HD machines. For those patients who are great candidates, do an up close machine demonstration while they receive in-patient hemodialysis.
For the patient who is highly motivated, but not 100% confident, consider investing in a trial of short daily HD training. If patient like it they can complete training. If they do not feel any better (which is unlikely), they will return to in-center HD.
Finally, a relatively high proportion of our patients have failed kidney transplants or other solid organ transplants that have renal failure as a consequence of chronic immunosuppression. Develop programs to attract these patients (Table 2).
“Leader” or “champion” needed
The medical staff needs at least one “leader” or “champion,” and preferably two, but everyone on the team needs to understand the special needs of the home patient. For example, one of our home HD patients had a beautiful arteriovenous fistula placed in his dominant arm because “the vein was better.” Luckily, he was ambidextrous because otherwise he would not have been able to self-cannulate.
Our vascular surgeon knows that the fistula needs to be in the non-dominant arm and a transposed vein needs to be placed in a position that the patient can get to. The leaders of the team should be both the physician and the nurse champion.
The physician needs to be the point person for patient recruitment, but along with the nurse champion develop staff education programs, policies and procedures, program development, and QA and CQI projects. The day-to-day operation of the program rests on the shoulders of the nurse.
Having a great nurse is the key to success so make sure you recruit the right nurses and invest in their education. Dietary restrictions improve but do not disappear with home HD, so a dietitian knowledgeable about frequent HD is essential. But the social worker is the key to identifying potential changes in the home that may lead to patient burnout or dropout from the program.