Speaker offers planning strategies for starting a new home dialysis program
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Home hemodialysis programs require investment in patients, staff, infrastructure and executive leadership to grow successfully and comply with federal models, according to a speaker at ASN Kidney Week.
“The model where you say, ‘well, let’s just start a program, and we’ll add a few patients, and then if we get more, we’ll add more patients and more resources’ – that rarely works,” Brent Miller, MD, Michael A. Kraus Professor of Clinical Medicine at Indiana University School of Medicine, said. “If you are going to succeed in this program, you will have to have a vigorous new dialysis program.”
Home hemodialysis programs should be ready to train staff, provide efficient monthly visits and effective education to patients, and prevent caregiver burnout.
Knowledgeable staff is an essential feature of a successful, patient-centered program.
“When you add a new home hemodialysis program, you’ll probably need to staff at a lower ratio particularly at the beginning because you’re training,” Miller said. He recommended a 1:10 ratio until the program matures.
Staff-to-patient ratios vary among mature programs, but investing in training will prepare staff to support patients and their loved ones.
“Let’s discuss the therapy at length with the family and the patient before training begins: What are our goals? What are your goals? What are my goals, as a physician, for you?” Miller said, explaining that it is important to set expectations, discuss training and implement it flexibly.
In caring for patients, it is essential not to overlook caregiver burnout: Miller said 61% of technique failures in the first 6 months at one U.K. program were attributable predominantly to burnout and other non-medical reasons. Respite care is a useful tool for supporting caregivers. Miller said that some of his colleagues insist on it once per year, although he does not.
Programs can also leverage telehealth. Miller suggested facilities consider how to “utilize it to have closer contact with the patient and their family during this first 6 months [when] they’re vulnerable.”
For a successful program, Miller also said “we need to make sure that we efficiently use all our other resources.” Executive leadership guides its financial, logistic and clinical decisions and “determine[s] your culture, so ultimately those are important,” Miller said.
Facilities should make financial decisions that are aligned with management structure and culture, Miller said, but also warned that new home hemodialysis programs often are not profitable for 3 to 5 years after inception. Many facilities scale patient numbers for 2 years, although, like other logistic decisions, the scope of that scale varies. Some programs may have fewer than 20 patients, while larger, mature programs may have 500 patients with 90 to 100 patients receiving care at home.
Nonetheless, without important investments, facilities limit potential growth. Miller cautioned against overlooking physical clinical space, noting that it improves the patient experience. He cited literature that suggests clinical space could affect staff perceptions of “the job you will do in taking care of the patient.”
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Miller B. Home hemodialysis: Key ingredients to setting up a successful program. Presented at: ASN Kidney Week. Oct. 22-25 (virtual meeting).
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