Workforce development and models of care in home hemodialysis

Setting Up Home Dialysis Programs: Now and in the Future

Home dialysis utilization has been growing in the United States over the past decade but still lags behind similar socioeconomic nations. More than half of dialysis facilities in the United States either are not licensed to offer home dialysis or, despite a license, have no patients dialyzing at home, and many programs have a relatively small census. Multiple stakeholders, including patients, health care providers, and payers, have identified increased home dialysis use as an important goal. To realize these goals, nephrologists and kidney care professionals need a sound understanding of the key considerations in home dialysis center operation. In this review, we outline the core domains required to set up and operate a home dialysis program in the United States now and in the future.

Expanding Utilization of Home Dialysis: An Action Agenda From the First International Home Dialysis Roundtable

In a groundbreaking meeting, leading global kidney disease organizations came together in the fall of 2020 as an International Home Dialysis Roundtable (IHDR) to address strategies to increase access to and uptake of home dialysis, both peritoneal dialysis and home hemodialysis. This challenge has become urgent in the wake of the coronavirus disease 2019 (COVID-19) pandemic, during which patients with advanced kidney disease, who are more susceptible to viral infections and severe complications, must be able to safely physically distance at home. To boost access to home dialysis on a global scale, IHDR members committed to collaborate, through the COVID-19 public health emergency and beyond, to promote uptake of home dialysis on a broad scale. Their commitments included increasing the reach and influence of key stakeholders with policy makers, building a cooperative of advocates and champions for home dialysis, working together to increase patient engagement and empowerment, and sharing intelligence about policy, education, and other programs so that such efforts can be operationalized globally. In the spirit of international cooperation, IHDR members agreed to document, amplify, and replicate established efforts shown to improve access to home dialysis and support new policies that facilitate access through procedures, innovation, and reimbursement.

Strategic Planning for Starting or Expanding a Home Hemodialysis Program

The American Advancing Kidney Health Initiative has renewed interest in home hemodialysis (HHD). Many perceived barriers exist for adoption of HHD despite well-reported clinical benefits. A well-designed program ensures patient success further engaging more patients. The initial planning regarding the surrounding patient population, stakeholders, economics, and physical location is essential. The services offered including modality education and different kinds of HHD modalities depend on local expertise and economics. The program should fulfill conditions for coverage requirements for personnel, physical infrastructure, and quality metrics to begin operations. The patient recruitment is facilitated by a patient-centric modality education program developed by the multidisciplinary team. If the patient is interested, a training schedule should be discussed with the patient and caregiver. A system to ensure remote patient monitoring, respite care, and 24 hours on-call availability should be established. These practical considerations ensure initial success and future growth of the program.

Challenges and Opportunities in Expanding Home Hemodialysis for 2025

The Advancing American Kidney Health Initiative has set an aggressive target for home dialysis growth in the United States, and expanding both peritoneal dialysis and home hemodialysis (HHD) will be required. While there has been a growth in HHD across the United States in the last decade, its value in controlling specific risk factors has been underappreciated and as such its appropriate utilization has lagged. Repositioning how nephrologists incorporate HHD as a critical renal replacement therapy will require overcoming a number of barriers. Advancing education of both nephrology trainees and nephrologists in practice, along with increasing patient and family education on the benefits and requirements for HHD, is essential. Implementation of a transitional care unit design coupled with an intensive patient curriculum will increase patient awareness and comfort for HHD; patients on peritoneal dialysis reaching a modality transition point will benefit from Experience the Difference programs acclimating them to HHD. In addition, the potential link between HHD program size and patient outcomes will necessitate an increase in the size of the average HHD program to more consistently deliver quality dialysis results. Addressing the implications of the nursing shortage and need for designing in scope staffing models are necessary to safeguard HHD growth. Seemingly, certain government payment policy changes and physician documentation requirements deserve further examination. Future HHD innovations must result in decreasing the burden of care for HHD patients, optimize the level of device and biometric data flow, facilitate a more functional centralized patient management care approach, and leverage computerized clinical decision support for modality assignment.

Physical Infrastructure and Integrated Governance Structure for Home Hemodialysis

In view of the growing enthusiasm for home dialysis use, new dialysis centers may build or expend their home hemodialysis program in the next few years. This review will discuss the main challenges faced by small and large home hemodialysis programs in terms of physical spaces, human resource, training considerations, and overall governance. We will elaborate on the inclusion of home hemodialysis in the kidney replacement therapy care continuum, with a specific interest for collaboration and transition between peritoneal dialysis and home hemodialysis programs.

Prospective monitoring of after-hours nursing and technologist support calls to a regional Canadian home hemodialysis program

INTRODUCTION

Increasing renal care providers offer home hemodialysis (HD) as a modality choice. There is considerable variation in the provision of after-hours on-call support for self-dialyzing patients and no literature describing the utility of this service. In this prospective, observational study we sought to monitor and classify the number and nature of interactions between home patients and our on-call nurses and technologists, and enumerate the number of adverse events averted by the availability of on-call staff.

METHODS

Our home HD unit provided 24-hour on-call patient support and during a 4-month period in 2012, we prospectively monitored all patient calls to this service. The nature of the calls was logged as nursing-related vs. technical. Call outcomes were classified according to whether patients were able to initiate/resume their treatments or whether additional interventions were required.

FINDINGS

During this period, our program cared for 58 home HD patients. Nurses fielded 172 calls and dealt with 239 issues. One hundred nine (46%) were clinical issues including 5 (2%) of a serious nature involving potential harm; 67 (28%) related to machine setup or alarms, 36 (15%) required a technologist to resolve, and 27 (11%) were deemed non-urgent. One hundred six issues were directed to technologists in 99 calls. Issues pertained to machine malfunction (45 calls-43%), machine set-up and alarms (25 calls-24%), or the water system (24 calls-23%). Only 12 calls (11.3%) were not of a technical nature. Nursing and technologist support allowed patients to initiate or continue their treatment 75% and 71% of the time, respectively.

DISCUSSION

Home HD on-call services provide patients support to successfully continue their dialysis treatments by troubleshooting clinical and technical aspects of dialysis and by averting potential adverse events.

Home hemodialysis in children

Pediatric home hemodialysis is infrequently performed despite a growing need globally among patients with end-stage renal disease who do not have immediate access to a kidney transplant. In this review, we expand the scope of the Implementing Hemodialysis in the Home website and associated supplement published previously in Hemodialysis International and offer information tailored to the pediatric population. We describe the experience and outcomes of centers managing pediatric patients, and offer recommendations and practical tools to assist clinicians in providing quotidian dialysis for children, including infrastructural and staffing needs, equipment and prescriptions, and patient selection and training.