Skilled nursing facilities, dialysis providers collaborate on care for patients with ESKD
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When Mark Kaszirer, LNHA, gets a call from a hospital looking to place a patient who needs short-term rehabilitation or long-term care, it creates an opportunity for one of his eight skilled nursing facilities.
When the hospital tells him the patient it is discharging also has kidney disease, Kaszirer, chief operating officer of Aventura Health Group, has that covered, too.
“If you have a [skilled nursing facility] SNF that takes dialysis patients on-site, it becomes a win-win for the patient and a win-win for the hospital,” Kaszirer told Nephrology News & Issues. “The key is becoming a responsive resource for the hospital when they need to discharge a dialysis patient. They will go with the facility that is the most efficient for their needs.”
Strong interest
Kaszirer heads a growing movement among SNFs to not only accept patients with end-stage kidney disease, but also provide the dialysis care patients need in its facilities. Larger dialysis organizations (LDOs) have responded, with both Fresenius Kidney Care and its NxStage subsidiary, as well as DaVita Kidney Care offering clinical teams to provide on-site hemodialysis.
On its website promoting its skilled nursing home dialysis program, NxStage reports that 65,000 patients are in SNFs with dialysis needs and “15% of all dialysis patients pass through a SNF” each year for rehabilitation after an injury or recovery from an illness.
Kaszirer partnered with Dialyze Direct for dialysis care in his SNFs. The company, which expanded rapidly in 2021 and 2022 with acquisitions, now provides dialysis services in more than 170 SNFs in Florida, Illinois, Indiana, Kentucky, Maryland, Missouri, New Jersey, New York, Ohio, Pennsylvania, Tennessee, Texas and Virginia, and recently formed a partnership with Satellite Healthcare to pursue business opportunities, such as hemodialysis and chronic kidney disease management for older patients in SNFs.
Dialyze Direct offers more frequent hemodialysis (MFD) in the SNF setting. Kaszirer said his residents felt better and were able to take full advantage of their rehabilitation program due to the shorter recovery time. He recently expanded his “dialysis den” to nine dialysis stations at his Adventura at Pembrook SNF in Westchester, Pennsylvania; about 10% to 15% of his resident patient population receive dialysis care at his facilities, he said.
The operational aspects of the management of patients on dialysis in SNFs are of interest to dialysis facility administrators, too. Kim Deaver, RN, MSN, CNN, program co-chair for the upcoming Renal Healthcare Association’s (RHA) Annual Conference in October (see Conference Preview on page 29), is including a presentation on the topic based on membership interest. Dialysis facility administrators for independent and LDOs make up RHA membership. “We added this to the program because it is a hot topic that is improving access to care for our patient population,” Deaver said.
Patient outcomes
A key question, sources tell Nephrology News & Issues, is determining whether residents of SNFs requiring treatment for ESKD have outcomes equally well or better than if they received care in a traditional outpatient dialysis setting. But national data for analysis of patient characteristics, modality options and clinical outcomes in SNFs have been difficult to track because CMS has used a “home dialysis” classification for these patients, Kirsten L. Johansen, MD, chief of nephrology and Hennepin Healthcare professor of medicine at the University of Minnesota and director of the U.S. Renal Data System (USRDS) Coordinating Center, told Nephrology News & Issues.
CMS has recently created a separate category for patients receiving dialysis in a SNF or a long-term care (LTC) facility, so data from this patient population can be tracked and studied.
“Considerable additional work was required to identify this group, such as ascertaining whether patients resided in facilities and whether dialysis providers were among those that focus on providing dialysis in these facilities,” Johansen said. “Now, SNF/LTC has been included as a dialysis setting, making it a simple matter to identify and distinguish home HD from HD in a SNF/LTC. This will allow USRDS and others to better track the uptake and outcomes of dialysis in both settings,” she said.
Patient benefits
Dialysis providers who offer services at rehabilitation facilities or nursing homes said there are multiple benefits for patients with ESKD who receive treatment on-site, including the following:
Caregivers avoid the need to transport patients, many who have frailty, are older and have other illnesses, to a dialysis clinic. Transportation is expensive, not always reliable and can increase the risk of infection if sanitary precautions are not followed or if travel must be done in inclement weather. “If your patient stays in your facility, they are safer, and you can guarantee that the patient is going to get their dialysis,” Kaszirer said. “Transportation companies can cancel on you or get delayed because they have a shortage of drivers, and my residents often had to wait at the dialysis facility to be picked up.”
Patients are not exposed to others in a dialysis facility who may have a communicable disease, including COVID-19.
Patients avoid missing appointments scheduled at the SNF, such as rehabilitation sessions, because they are receiving dialysis off-site. Likewise, meals and medication rounds can stay on schedule.
Dialysis providers also can offer more frequent dialysis as an option in the SNF. In a study recently published in Hemodialysis International, patients who received MFD in SNFs had a shorter recovery time compared with patients undergoing conventional dialysis. “Compared to the benchmark post- [dialysis recovery time] DRT of 8 to 21 hours for conventional dialysis, 92% of residents with more frequent dialysis recovered within 2 hours and 80% recovered within 1 hour,” Allen M. Kaufman, MD, lead study author, told Nephrology News & Issues. “Thus, even the elderly, frail SNF residents with multiple complex medical conditions benefit from more frequent dialysis.
“The results are highly promising in potentially enhancing the ability of these ESKD patients to participate in rehabilitation and restorative services while living in the SNF,” Kaufman, chief medical officer and senior vice president of clinical and scientific affairs at Dialyze Direct, said.
Acuity
The medical burden that many patients with ESKD bring to SNFs exacerbates their ability to manage their kidney disease, Kaufman said. “We all know that the [ESKD] patient population, in general, is a major user of health resources. Within that group, there is a subgroup that is even more complex and even a bigger user of health care resources, and those are the patients who tend to show up in the skilled nursing facility.”
Over the last few years, a growing number of patients who need to be admitted to a SNF are also new to dialysis, Kaufman said. “It is not ideal but, by and large, the vast majority of people who start dialysis do so in the hospital. We are all thinking of a future world where all these pre-ESKD patients are closely monitored by the interdisciplinary team that is already on-site in the nursing home. Therefore, you can start their dialysis in an elective way without them ever going to the hospital.
“But right now, less than 20% of patients who go to SNFs start that way.”
Having the interdisciplinary team on-site provides an opportunity to better manage CKD among this patient population, Kaufman said, “affording them the chance to be educated and experience, when needed, the home hemodialysis modality. This is an opening for dialysis companies trying to breakdown the excessive barriers and offer health care equity to minorities and the lower socioeconomic population.”
Patient management
Dialysis providers bring in their own staff and equipment to manage the treatments in a SNF; state and federal licensing requirements are under review that would allow trained nursing home staff to provide dialysis care, Alice Hellebrand, DNP, RN, MSN, CNN, chief nursing officer and vice-president of education at Dialyze Direct, told Nephrology News & Issues. “Regardless, we believe the ultimate responsibility of the dialysis-related training and oversight of these caregivers will continue to be the dialysis provider’s responsibility.
“We are responsible for the dialysis treatment and the care that occurs within the den setting, which means that there is a collaborative handoff that occurs between the skilled nursing home and dialysis staff around the status of the resident, any medication changes, and any laboratory results that they may have,” Hellebrand said. “That handoff goes to the dialysis staff, which includes a registered nurse managing the den along with either a certified patient care technician, a licensed practical nurse or licensed vocational nurse.
“If the patient requires ancillary care, such as a medication, we notify the skilled nursing home team and they come and assist. Then there is a reverse communication handoff to the skilled nursing home,” she said.
Future
Kaufman said the patient population in SNFs is constantly evolving. “Ten years ago, if you sent a patient from the hospital to the nursing home, that patient had to be strong enough to get onto a van and go to an outside dialysis unit during their rehabilitation period. And there was a whole group of patients who could not do that. They never left the hospital.
“Now, we have options for these patients. As we developed our abilities to understand this population, to coordinate with the nursing home and the staff, we have improved the product that we deliver. But the hospitals are sending patients who are even more complex now. Our model will have to have subsets that are patient centric to this specialized kind of patient who is coming into the facilities. I think that is going to be evolving rapidly,” Kaufman said.
Kaszirer said dialysis care in his SNFs is successful because there is collaboration between the dialysis provider and the facility clinical staff on patient care.
“It’s only possible if you have a SNF-focused dialysis provider and an engaged clinical team,” he said.
- References:
- On-site home hemodialysis for dialysis providers. NxStage from Fresenius Medical Care.
- www.nxstage.com/administrators/snf-providers/
- www.healio.com/news/nephrology/ 20220506/older-adults-on-frequent-dialysis-in-skilled-nursing-facilities-report-rapid-recovery
- For more information:
- Alice Hellebrand, DNP, RN, MSN, CNN, can be reached at alice@dialyzedirect.com.
- Kirsten L. Johansen, MD, can be reached at kirsten.johansen@hcmed.org.
- Mark Kaszirer, LNHA, can be reached at mark@aventurahg.com.
- Allen M. Kaufman, MD, can be reached at allen.kaufman@dialyzedirect.com.
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