Solo nephrology practices can succeed at directing patients home
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There has been a great deal of focus recently in getting more patients interested in home dialysis.
The timing of this approach is important: HHS has issued a directive to the kidney community to have 80% of patients either starting home dialysis or in possession of a functioning transplant by 2025.
That goal is ambitious. Currently, 10% to 12% of patients in the United States are dialyzing at home. Yet a significant increase is not impossible, and the results are worth the challenge.
Home dialysis is patient-directed and fosters independence and self-worth. It allows the patient to remain productive in the workforce or in family units at home, leading to better patient satisfaction. Patients on home dialysis also use fewer resources overall, require fewer medications and have fewer hospitalizations, reducing the overall cost of care.
In my solo practice in south Louisiana, we have demonstrated how to grow the home dialysis population to nearly 40%. Our program is rooted in the belief that most patients can learn how to care for themselves. Physician bias often leads to patients being denied the chance to succeed; with the right approach, we can make significant gains.
Low-key start
I began my program in 2008 with one nurse and one patient who had expressed interest in home dialysis. As our program grew, we had victories but also failures — not from picking the wrong patients, but from following the wrong approaches.
Many patients doubt their own ability to care for themselves and are apprehensive about making decisions regarding a dialysis modality. As we gained more patients and expanded our program, my nurses and I learned the key to effective care was approaching all patients with confidence in their ability to take control of their treatment and encouraging them to try. We did not promise success, but we did promise opportunity — and our method has shown real and important results.
Direct approach
Our approach is methodical and direct. Beginning when a patient reaches a GFR of 20 mL/min/1.73 m2, I offer options education. I have the patient come to the clinic for a tour, which is scheduled on our home dialysis clinic days, and allow the patient to engage directly with another patient who is already doing home dialysis. These “patient ambassadors” humanize home dialysis by discussing the details of their therapy, as well as their experiences with the more personal challenges of home dialysis, like sleep, intimacy and partner engagement.
At the conclusion of this meeting, patients also see the dialysis floor and learn how in-center dialysis is structured.
This personal and reassuring approach helps patients reflect on their choices, demystifying the experience and taking some of the fear out of the process. During the nearly 10 years I have used this technique, more than 90% of my patients have chosen home dialysis.
Of course, not every home dialysis patient is a new patient. We also approach our current in-center population each month, engaging patients who would be well-served by home dialysis, as well as those facing new circumstances that could influence new choices, from access complications, improvement in the home situation, fears about communicable diseases or general health. In southern Louisiana, as we grapple with hurricane threats for 6 months each year, home dialysis can be a safer and more comfortable option. With the added threat of COVID-19, home options have taken on a greater importance and have found a more willing audience.
Opportunities for growth
Going forward, I anticipate the use of home dialysis will grow. Our current high-risk population is younger and will likely develop end-stage kidney disease at an earlier age. They are more tech-savvy and more apt to expect health care on demand. These characteristics are likely to make home dialysis the first option for our future patients. As clinicians, it is our responsibility to prepare for that future.
We must change our own attitudes about these therapies and stop being paternalistic. We must be open minded and recognize most patients are candidates for home dialysis. Nearly all of us would choose home care for ourselves or a family member. Our patients deserve the same approach.
- For more information
- Shaminder Gupta, MD, is the immediate past president of the National Kidney Foundation of Louisiana and the leader of its home dialysis task force. He also serves as the section chief of nephrology at Leonard J. Chabert Medical Center in Houma, Louisiana. He can be reached at shaminder.gupta@monogramhealth.com.
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