Helping dialysis patients gain independence

If we hope to be successful in a rapidly changing health care environment, dialysis providers can’t afford to maintain the status quo. “Successful” doesn’t just refer to financial stability; it also means providing good quality care for our patients.

During our strategic planning sessions at the Dialysis Center of Lincoln over the last few years, we have been discussing how we could offer a different dialysis experience. We think the way we start in-center dialysis today removes the patient from engaging in their own care and results in depending on the staff for all their needs.

Specifically, we wanted to find ways to engage our patients into a period of transitional care at the start of their dialysis. We defined transitional care as an opportunity for our patients to experience more frequent dialysis at the beginning of their dialysis care, allowing a patient to receive the care needed in a manner that best fits their personal goals. This opportunity includes offering a glimpse of how they might manage hemodialysis treatments at home.

In late 2015, we learned about dialysis machine manufacturer Outset Medical through one of their employees that had worked for us. Outset asked us to assist them as they developed a few of the components of a new hemodialysis system called Tablo. Their technology looked like the kind of tool we could use to advance our transitional care idea.

In early 2016 the Dialysis Center of Lincoln began trialing the Tablo at one of our units; after a number of months, we decided to expand the program into three of our dialysis clinics. We currently have 12 Tablos in use.

Role of technology in transitional care

The Tablo helps us meet a few objectives for a transitional care program.

Patient friendly

Tested, computer-based patient education (introducing the patient to setting up the Tablo, starting the treatment, monitoring the treatment and troubleshooting problems as they arise)

As patients work with their in-center nurses, we see they quickly become engaged with their treatment experience and the outcomes, such as achieving proper “dry weight” and blood pressure control. Their engagement also helps us to identify candidates who would do well in the home hemodialysis program. We have found patients like Tablo and generally say they feel better after their treatments.

Moving forward

As a small provider, we intend to go slowly with this new technology. We are not in a position to go “all in.” But with only a conceptual definition of transitional care in mind, we decided to move forward without a playbook on hand. With the help of Outset we began offering assisted dialysis at a 12-station unit in Columbus. Outset helped us train our manager and dialysis staff, so they were comfortable with the technology and procedure.

At the same time we began to talk with patients and identified four of our current in-center patients who expressed an interest in trying Outset in a staff-assisted model. It was a self-selection process, and we provided information and the opportunity for them to decide if they wanted to make a change. We still are fine tuning the criteria for patient selection, and have had a few false starts.

Staff assisted means that we supported the dialysis treatment 100% like we normally do and let the patient go through the education modules so they become more and more comfortable with the process. At the same time, it allows them to take on responsibilities and skills needed to assume more and more of their dialysis care and monitoring their treatment in a step wise fashion.

Some individuals progressed very quickly and within a week were getting close to managing the entire dialysis treatment independently, including putting in their needles. Others struggled, needing ongoing assistance, additional time, or simply deciding not to continue. Our experience with training home hemodialysis patients is very similar.

The patient determines their pace of progress, as it is a learning process, not a race. Our primary objective early on was to merely determine if we offered an assisted alternative, was there a reasonable number of patients who would be willing to try it? We felt there was enough patient interest to expand the demonstration into two additional clinics, which we have done over the past year. We have found staff and patients willing to try a new way to dialyze and are encourage with the positive response to the experience.

We started in Columbus, for example, primarily because our nurse manager was interested in changing the dialysis process and made a commitment to the three-month demonstration project.

Future plans

Our next step is to take our experiences and incorporate them into a more formalized and focused transitional care program. We are building a new unit in Lincoln set to open in 2018 and have dedicated space in our treatment area so we can offer the program to create a “new patient” start program.

We intend to continue to offer Tablo at other units as we don’t believe limiting access to one location will allow the program to grow and benefit patients.

Avoiding the status quo and providing patient a different experience as they transition to dialysis as well as during their ongoing treatment in-center or at home is the goal of our effort. - by Larry Emerson