Assessment tool can help clinicians create a home-first culture
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For some patients, home therapies are preferable to in-center dialysis treatment. This option has been associated with improved patient outcomes and increased overall quality of life for many patients with end-stage kidney disease.
Patients using peritoneal dialysis or home hemodialysis (HHD) often have a more flexible diet, take fewer medications and are able to follow a customized treatment schedule. This aligns with the Advancing American Kidney Health initiative’s goal of 80% of new patients in 2025 receiving dialysis in the home or receiving a transplant.
Despite these goals and potential benefits, home dialysis adoption remains limited. To increase the uptake of home treatment, it is important for dialysis center staff to efficiently cultivate a home-first culture that empowers them to identify suitable candidates and address potential barriers.
Several strategies can be implemented to help in-center dialysis patients transition to home therapies, including the use of transitional care units (TCUs). These have been proven effective in addressing barriers to home dialysis; however, not all dialysis centers have the resources or space to operate TCUs. As an alternative, patient assessment tools can be used in any clinical setting with very few resources.
Assessment tool
Our staff at a unit of a large dialysis organization, in partnership with Geisinger Medical Center in Danville, Pennsylvania, implemented a home dialysis education project using the Method to Assess Treatment Choices for Home Dialysis (MATCH-D; Medical Education Institute) tool. This assessment instrument uses a simple questionnaire to help identify and assess patients who may be eligible for home therapies. The criteria outlined in the tool identify possible barriers to home dialysis and help determine if those barriers are modifiable.
The color-coded tool categorizes suitability criteria into three groups: green for no significant barriers, yellow for presumed obstacles or potentially modifiable barriers and red for barriers that indicate that the patient may not be eligible for home dialysis.
This straightforward system allows for quick assessments that can be easily integrated into routine clinical practice, enabling providers to discuss these factors with their patients in shared decision-making for each patient’s care plan.
Dialysis centers
Most patients in the United States start with in-center hemodialysis, but by aligning the clinic mission to patient-centered care, priorities can be shifted and more patients can transition to home therapies. Integrating the MATCH-D tool into the dialysis clinic’s regular assessment processes would maximize its benefits. Assessments should be conducted frequently, ideally at every patient admission and as part of ongoing evaluations.
At our dialysis center, assessments became an integral part of our admission process. During each admission, we assess the patient’s suitability for home dialysis using the tool, documenting the results and revisiting them regularly to monitor any changes in the patient’s condition or circumstances. After repeated use, staff has an intuitive understanding of the tool and can quickly identify patients who match the “green” criteria and encourage training for home therapies.
Shifting the clinical mindset to prioritize home dialysis can be challenging, particularly in centers where in-center treatment has long been the standard of care. However, surveys indicate that more than 90% of nephrology professionals would choose home therapies for themselves. Staff education, motivation and constant patient assessment are essential to overcoming these challenges.
Additionally, it is important to include patients in the conversation about their treatment options, listen to their concerns and create an individualized action plan. Because MATCH-D is part of our routine admission process and staff know what questions to ask, it becomes more of a conversation than a test. When staff get to know a patient, their environment, who they care for and what is important to them, patient needs can be understood. Everyone in the clinic must be on the same page, working toward the same goal of supporting patient-centered care at all stages of their journey.
Self-cannulation
Many patients are interested in transitioning to home hemodialysis but are fearful of self-cannulation. To address this common barrier, staff implemented a self-cannulation program within our in-center hemodialysis unit. This program provides patients with the cannulation skills and confidence needed to manage their treatment at home. From the outset, patients are included in the conversation, with providers listening to their concerns and developing individualized action plans to address their unique challenges.
Group training is a valuable technique for transitioning patients from in-center dialysis to home, fostering a sense of community and enriching learning. A group setting allows patients to learn in a collaborative environment where they can share experiences, ask questions and provide peer support. Ultimately, in our experience, this helps improve the patient’s transition to home dialysis.
Consistent evaluation is a crucial aspect of implementing MATCH-D use. We found that we were able to identify patients who may be suitable for home therapies, even if they have been in-center for many years. A motivated team can then work to overcome barriers while supporting lifestyle preferences like pet ownership, travel or certain hobbies. This tool may be used at any time, and its regular use ensures that no patient is overlooked.
For this reason, we review all patients quarterly using MATCH-D. Adopting this habit has been instrumental in aligning our mission and vision with the goal of increasing home therapy transitions. We commonly see patients who have been in-center for long periods of time, and we are able to identify barriers.
It is also important to recognize that some barriers may, in fact, be modifiable with the right resources and a creative mindset. In one instance, our clinic was able to turn a “red” barrier “green” with a wealth of ideas and a problem-solving-mindset.
Moving the needle
According to the latest U.S. Renal Data System Annual Data Report, 5% of centers certified to offer home dialysis in 2021 had more than 20 patients on HHD. Thanks to motivated staff who understand and emphasize the MATCH-D tool as part of our home-first culture, our center grew from nine patient on HHD in 2022 to 34 patients on HHD through August 2024.
The MATCH-D tool is a powerful resource for nephrologists and dialysis care teams committed to expanding the use of home therapies. By integrating it into routine practice, fostering a home-first culture and maintaining a focus on patient-centered care, clinics can significantly increase the number of patients who successfully transition to home therapies. This not only has the potential to enhance patient outcomes but also aligns with the broader goals of the Advancing American Kidney Health initiative.
To download a copy of MATCH-D, go to https://homedialysis.org/match-d.
- References:
- Annual Data Report. United States Renal Data System. https://usrds-adr.niddk.nih.gov/2023/end-stage-renal-disease/2-home-dialysis.
- Bermudez MC. Am J Kidney Dis. 2024;doi:10.1053/j.ajkd.2024.01.427.
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- For more information:
- Maria Camila Bermudez, MD, is an assistant professor of medicine and associate program director of the nephrology fellowship at Geisinger Medical Center, Danville, Pennsylvania. She can be reached at mcbermudez@geisinger.edu.
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