Just thought I would let you all know I’ll be adding a request for home dialysis regional training centers to the wish list we’ve come up with (see above)
What is meant by regional training centers? Hope is doesn’t mean that patients/caregivers would have to travel a considerable distance and pay for a motel to get training for home dialysis.
Don’t know yet. This is something that will have to be worked out. We have time, nothing is going to happen until the next legislative session starting in January 2009 - maybe not even then, I’m guessing it might be something the Colorado state board of health might decide? - that is if we get a bill together and if we can get it to pass.
Here are some things I’ve thought about arelated to regional training centers. Jane brings up a good point that some people may not have the resources to travel to a regional training center or may have other concerns about being miles away. Here are some possible ways to address that.
– Seek Medicaid payment for transportation (if required), lodging and meals (per diem) for Medicaid recipients (low income, limited assets) who must travel more than say 100 miles to get training (is 100 miles too far?). At one time Kansas did that.
– Encourage regional training centers to investigate whether commercial insurers will pay for transportation or lodging for distant patients who choose home treatment as some do when they send patients for transplant at “centers of excellence.”
– Encourage the regional training center to negotiate rates with nearby motels. Having a regional training site in an underserved area might bring in business to the community.
– For daily dialysis, have the regional training center advocate with Medicare for reimbursement more than 3 times a week. The history of payment for home HD is that this modality was offered 3 times a week…now it’s offered more days. If the training limit is 25 training sessions, it shouldn’t make any difference how many times a week those sessions are offered and for those needing to travel to training, being able to get 5 or more days of training a week would shorten the time required.
– Any regional training center must have an arrangement with clinics (or corporations) in the state so patients who get training at the regional center has a facility where he/she can get backup.
– The regional training center would allow patients to have labs drawn in their local community with results shared with the patient and the regional training center.
– The regional training center would have open privileges so any nephrologist could refer any patient to the training center and the patient could have regular appointments with his/her nephrologist is his/her office in addition to having clinic visits at the regional training center.
– Consider the regional training center the patients’ “home” facility. Assure that there is 24/7 availability (toll-free phone number) of an experienced nurse for any modalities offered. Although patients would need to travel to that facility for clinic visits, they could be assured that if they needed help, an experienced nurse would be on the other end of the line. The training center’s dietitian and social worker would also be experienced in issues faced by home patients so they could offer answer questions and counsel with patients/families.
– Consider establishing regional training centers that are designated as “centers of excellence” and establishing criteria that would include at minimum an evaluation of their staff’s competence in home dialysis training and support and meeting certain outcomes (low rate of infections, low rate of hospitalizations, higher than average patient functioning).
I believe having training centers of excellence would be a way to allow physicians affiliated with facilities that don’t want to start a home program (and that they can’t convince to offer home dialysis) to refer their willing patients to a home training program that will work with the nephrologist to assure the patient is getting the best care to live a good life on dialysis.
How far would patients be willing to drive to get that level of care?
Hi Folks
My cut off as to travel was and is 50 miles one way. If the units that offered programs were outside that I would have stopped dialysis “in center” at the first unit I was told to go to ,due to the conditions. We just talked on this at the unit I go to now, and I said ""what about if a person wants to do a home tx then why not have the hospital where your Dr is do the training?’’'I was telling my unit folks that in the event of needing a hospital I’m going to the nearest hospital. I would not travel to a unit that I had to stay there in the area I have too many things that I take care of , where would I go for my monthly. The rules now say I must go to where I was trained ,no matter the hardship on me $$$ wise. Isn’t that what dialysis is crying about ,the lack of money as to why more centers do not have training programs outside of a PD program.
bob obrien
Beth I like your ideas. The thing is, they would work for some patients, but not for others. The expense issue is one of the most important ones, so if expenses were covered, that would certainly help. It could also be a hardship on a family to either have to quit one’s job or lose the income from one’s job in order to go for weeks of training. And some patients have many other responsibilities that would be greatly hindered by having to travel and stay a distance away ( i.e children to care for, elderly parents that need care, other duties).
With that said, it is important to consider patients’ energy levels and ability to handle stress when it comes to traveling a distance to get training, the training itself, staying in motels, eating out everyday, being in close proximity to caregivers with their faster pace and pension for more noise and excitement etc. Every dialysis patient is different in what they can handle, but I know for myself, stress is my mortal enemy. I do everything I possibly can to avoid stress, but even my closest family members and my dialysis team do not comprehend how stress affects me. Stress affects me because my low kidney function means I don’t have the reserves to function as a healthy person functions. If I go at too fast or too stressful a pace for me, it puts me over the edge. The energy I do have evaporates quickly.
When I get stressed, I get thirsty and since I have to watch how much I drink, I can not reach for a drink of water every time I need it. Stress also affects how well I can train. So, the last thing I want to do is travel a considerable distance to get training or to get training when I am staying at a motel. That’s me - but I’m sure many other dialysis patients would have similar limitations/concerns.
Just driving to my clinic each day, 15 minutes away, was enough stress for me when I did SDD training. Then the training, itself, was pretty stressful as I don’t have the stamina to go through hours of training day after day. Of course, there is training and then there is training, meaning if trainers are excellent at what they do, that would provide less stress for patients. But just because someone is a nurse does not mean she/he is a good teacher/ trainer or is sensitive to patients needs.
I was loaded down with stress at my training and survived it. It was worth it to get better txs at home. But my point is, it is important for those who write the laws to gain an understanding of the nature of kidney disease/dialysis so they can realize how it affects dialysis patients and write laws for home training, accordingly. And considering that post training one would have to travel to the regional training center monthly for clinic apointments, I would want to travel no more than a distance of an hour’s drive. But even that is excessive. It seems to me a better solution would be to offer dialysis companies a financial incentive to offer the full range of home txs so that at least every city would have one clinic, at a minimum, that patients could easily get to. Maybe this, plus regional centers, would open the way for more patients to get home dialysis, including the home modality of their choice that best compliments their lifestyle and personal needs.
I’m sending my state rep many of your comments about regional training centers and will see what we can do. I did get an email back from him and he wants to look at this more when the legislative session is over here in Colorado.
Hi Folks
Hey Plugger
Can you in a nut shell , did you or were you always into the poltico scene? did you just pick a local state rep or is the guy from your area? Was he aware of dialysis issues? How long have you been working on this?
Any ideas on how to go about this, you things we should talk on and not talk on?
Bob obrien
Awhile back I started working inSecond Life and met several people awaiting transplants and also met someone running a group for “Organ & tranplantation” and found that no one there thought dialysis was the way to go. I was only one in that group that did home dialysis and when I spoke about the goodness of self care and home dialysis everyone just remained silent. As if a BIG tornado just came in or something.
Anyway, I think many people are mis-informed about frequent dialysis and that dialysis is not the whole end, so I think awareness and education is the key to breaking down the myths.
On the other hand, I really think most people will try to avoid dialysis by getting a transplant firsthand, no doubt about it…
[QUOTE=bobeleanor;15773]Hi Folks
Hey Plugger
Can you in a nut shell , did you or were you always into the poltico scene? did you just pick a local state rep or is the guy from your area? Was he aware of dialysis issues? How long have you been working on this?
Any ideas on how to go about this, you things we should talk on and not talk on?
Bob obrien[/QUOTE]
Bob,
I guess I really started this during the 2004 election - I wasn’t much into politics before that. I recall sending all the politicians in my area an introduction to dialysis I made up. I got a lot of nice replies from most of the people I sent it to - but I do recall not hearing a word from the person who is now my former state rep. The fellow running against him seemed very interested in what was going on and I decided he was the kind of guy I wanted to help - he was also an advocate for single-payer Universal Health Care, which I’m very much in favor of. Anyway, I volunteered for his campaign and walked door-to-door with him - where we got to talk more about things, wrote letters to the editor for the local paper, and contributed to his campaign. He lost the 2004 election, but won in 2006. By that time he seemed more than happy to get a bill started. I should also mention I go to the same church as my state senator and he got the bill through the senate for us and helped start the Colorado Department of Regulatory Agency investigation that precluded the bill - though that didn’t go as well as expected. You can read about all this at:
Colorado Tech bill Story topics (4 parts) and Colorado Technician Training Standards Hearing topic:
http://www.patientrightsadvocacy.org/forum/viewforum.php?f=3
I think I could dig up that intro I wrote years ago if you want it and give you my contact info if you write plugger2us@yahoo.com.
I can definitely see a need for more education about home dialysis, if I hadn’t run into a friend who was on it years ago I would be looking at people like Gus like they were from Mars too.
Hi Folks
Hey Plugger
Thanks , I have a letters, ready to go out to my state reps and Dc reps, plus my state AG. It has been a long time coming, but I wanted to be sure I have a paper trail and time in dialysis to (seeing a poor unit & a good unit) My trip into dialysis should not have gone the way it did, I know how to deal with medical people from all my yrs in and out of dealing with all sorts of medical people with the dialysis world being the only group I did not deal with till this came about. . I would like to see this nation wide. I have been saying since this started centers need to have better rules as to techs, and unit conditions. If the center I’m in now can make up the pt area the way they do, then all centers should have the basic same set up. Also I want to think that poor units are rare, but all the more reason to get them up to par. . Plus the people I’m talking with now seem to feel the same, that techs at least need more training on people to people skills and have to understand what is being placed into there hands. Now before any techs start sounding off , I know that most techs do a good job , but it only takes one .
bob obrien
I hope things are going good for you Bobeleanor!
I figured it was about time for an update on what could be done legislatively to help promote home dialysis here in Colorado. I gave the list of suggestions to my state senator and last I heard he was looking it over and he did make the suggestion I might consider forming a non-profit to accomplish many of the objectives - I might have to think about that one. It would be a really big step and I’m not sure I could pull it off.
I also gave the list to my state rep and he did ask if any other states have done something similar? I don’t have an answer for that one.
I also just heard from my rep about some neighbors he ran into. One of them has a father who is on dialysis here in town and they are upset about the high tech turnover they are seeing and the fact the father came home one day with blood all over his clothes. I did mention one thing I hope I would consider under such circumstances - home dialysis. I used the search on this website and found three places in Denver and Lakewood Colorado that offer both nocturnal and daily dialysis and sent off the info to my rep - that is a great feature!!
Bob,
Hopefully, new ESRD Conditions for Coverage (regulations) that take effect October 14, 2008 will help standardize the quality of care provided by dialysis technicians. The new regulations require that all newly hired technicians be certified by a state certification program or a national certification program within 18 months of their hiring and further require current technicians to be certified within 18 months of October 14, 2008. Technicians must “meet all applicable State requirements for education, training, credentialing, competency, standards of practice, certification, and licensure in the State in which he or she is employed as a dialysis technician,” they must have a high school diploma or GED, and they must “have completed a training program that is approved by the medical director and governing body, under the direction of a registered nurse, focused on the operation of kidney dialysis equipment and machines, providing dialysis ipatient care, and communication and interpersonal skills, including patient sensitivgity training and care of difficult patients.” The section on personnel specific to technicians specifies 8 areas that must be addressed in the training program.
The regulation is posted online at:
http://www.cms.hhs.gov/CFCsAndCoPs/13_ESRD.asp (see ESRD Conditions Final Rule when you scroll down the page)
The last 10 pages are the actual regulations. The pages before that describe the history, respond to comments and explain decision making behind the regulations.
Finally, in the section on care at home, the nurse responsible for a home or self-care training program must be a registered nurse with 12 months of nursing experience plus 3 months experience in the treatment type they’ll be training patients to do.
[QUOTE=Beth Witten MSW ACSW;16212]Bob,
Hopefully, new ESRD Conditions for Coverage (regulations) that take effect October 14, 2008 will help standardize the quality of care provided by dialysis technicians. The new regulations require that all newly hired technicians be certified by a state certification program or a national certification program within 18 months of their hiring and further require current technicians to be certified within 18 months of October 14, 2008. Technicians must “meet all applicable State requirements for education, training, credentialing, competency, standards of practice, certification, and licensure in the State in which he or she is employed as a dialysis technician,” they must have a high school diploma or GED, and they must “have completed a training program that is approved by the medical director and governing body, under the direction of a registered nurse, focused on the operation of kidney dialysis equipment and machines, providing dialysis ipatient care, and communication and interpersonal skills, including patient sensitivgity training and care of difficult patients.” The section on personnel specific to technicians specifies 8 areas that must be addressed in the training program.
The regulation is posted online at:
http://www.cms.hhs.gov/CFCsAndCoPs/13_ESRD.asp (see ESRD Conditions Final Rule when you scroll down the page)
The last 10 pages are the actual regulations. The pages before that describe the history, respond to comments and explain decision making behind the regulations.
Finally, in the section on care at home, the nurse responsible for a home or self-care training program must be a registered nurse with 12 months of nursing experience plus 3 months experience in the treatment type they’ll be training patients to do.[/QUOTE]
Wow, did I just read what I thought I read???!!! Hard to believe that the ESRD program is finally instituting national tech certification. Does tech certifcation apply only to pcts without licenses or to LPNs and RNs as well? I hope the state and national certification programs are stringent enough. From what you are saying here, many of the opinions of patients and professionals in the comment period were adhered to. It sounds like a major step in the right direction- just hope there are new regs in regard to enforcement, because without enforcement, no matter how good regulations are, they remain limited or worthless.
When it says the head of a home hemo dept. must be an RN, does that mean the nurse who actually delivers the care (mine is a LPN) or an RN designated to cover the program?
Guess I’ll go get a cup of tea and settle in and begin this 116 pg. read. Happy 4th of July everyone!
Technician certification applies to patient care technicians, not LPNs or RNs. In most states, as we’ve discussed here before, technicians are unlicensed and uncertified. The Core Curriculum for Dialysis Technicians on the MEI website at http://www.meiresearch.org/CoreCurriculum/index.php offers excellent training for technicians. The preamble (the part of the Conditions for Coverage before the actual regulation) suggests this as one way to train technicians. In the clinic where I worked, a previous edition of this manual was used to train every new RN, LPN and technician who had not worked in dialysis.
RNs and LPNs are currently required to pass exams to meet state practice requirements and be licensed. If they violate state nurse practice acts or act outside the limits of their license, they can lose their right to practice. Patient care technicians have not had to prove competency, but with the new regulation they will.
Jane, in response to your question about the status of the LPN who trained you, currently the regulations do not specify who else besides the RN responsible for the self-care and home training program will be allowed to train patients. I suspect this will be addressed in the interpretive guidelines that are being written now and will be published as soon as they’re approved. When the interpretive guidelines are published, I’ll provide a link to them.
[QUOTE=Beth Witten MSW ACSW;16217]Technician certification applies to patient care technicians, not LPNs or RNs. In most states, as we’ve discussed here before, technicians are unlicensed and uncertified. The Core Curriculum for Dialysis Technicians on the MEI website at http://www.meiresearch.org/CoreCurriculum/index.php offers excellent training for technicians. The preamble (the part of the Conditions for Coverage before the actual regulation) suggests this as one way to train technicians. In the clinic where I worked, a previous edition of this manual was used to train every new RN, LPN and technician who had not worked in dialysis.
RNs and LPNs are currently required to pass exams to meet state practice requirements and be licensed. If they violate state nurse practice acts or act outside the limits of their license, they can lose their right to practice. Patient care technicians have not had to prove competency, but with the new regulation they will.
Jane, in response to your question about the status of the LPN who trained you, currently the regulations do not specify who else besides the RN responsible for the self-care and home training program will be allowed to train patients. I suspect this will be addressed in the interpretive guidelines that are being written now and will be published as soon as they’re approved. When the interpretive guidelines are published, I’ll provide a link to them.[/QUOTE]
It is interesting to me that RNs and LPNs don’t have to be certified in dialysis since they come to dialysis without dialysis skills just as the techs do. I have had numerous nurses in dialysis who can not answer basic dialysis questions and who have poor dialysis skills. It seems to me they need the same certification the techs must now get. As a patient who has gotten dialysis services at a number of clinics, thus have experienced many dialysis staff, I have often gotten the nurses and the techs mixed up, because techs sometimes do a better job than the nurses- I would often say, “Are you a nurse or a tech?” ( that’s another thing- often they never even introduced themselves). So, I have always felt that the nurses need certification in dialysis as much as most of the techs. With the new certification regs, the techs might surpass the nurses in dialysis knowledge and skills. Then that will be another problem lol. But this certainly is a big development for patient care. Thanks for keeping us abreast…
[QUOTE=Beth Witten MSW ACSW;16212]Bob,
Hopefully, new ESRD Conditions for Coverage (regulations) that take effect October 14, 2008 will help standardize the quality of care provided by dialysis technicians. The new regulations require that all newly hired technicians be certified by a state certification program or a national certification program within 18 months of their hiring and further require current technicians to be certified within 18 months of October 14, 2008.
[/QUOTE]
This is great to hear! It appears our law in Colorado for tech certification maybe overridden by the federal law - our clock for the 18 month wait for certification didn’t start until January 1, 2009. If the feds have something better here I’m all for it!
Our effort here in Colorado was worth it though just to educate our state legislators about the goings-on in dialysis. I’m going to have to read more about this new federal development.
I think state efforts to require technician certification led dialysis providers to support certification in their comments when CMS published the draft federal regulations. I suspect they didn’t want to have to deal with 50 different interpretations of what was needed. So far as technician certification in states, whichever regulations are more stringent will be what state surveyors surveying dialysis clinics will expect to see.
So far as to nurses vs. technicians, technicians can be very good at dialysis because that is what they’ve been taught. However, they may not do as well as an RNs in assessing and troubleshooting problems because they don’t have the years of nursing education that RNs have received. Here’s a renal career fact sheet on nephrology nursing from the NKF:
http://www.kidney.org/professionals/CNNT/nurscnnt.cfm
Certification is available for nurses. Dialysis clinics can encourage more nurses and technicians to be certified by helping with the cost of obtaining the certification and paying more for certified personnel. Here are a couple of the certifying agencies for nurses and technicians:
http://www.nncc-exam.org/
http://www.bonent.org/
This was good to read. As soon as the warm glow from hearing the feds are stepping in wore off my ingrained distrust of for-profit dialysis set in and I recalled an incident that happened at the state capitol with some people from the dialysis companies.
Reps from Fresenius and DaVita were there at a stakeholders’ meeting. One thing our side got upset about was a DaVita rep trying to push their training program as so good it should allow their techs to be exempted from our bill’s certification requirements; we shot that down real quick.
I hope the same sort of exemptions won’t be tried with this federal bill.
[QUOTE=Beth Witten MSW ACSW;16225]I think state efforts to require technician certification led dialysis providers to support certification in their comments when CMS published the draft federal regulations. I suspect they didn’t want to have to deal with 50 different interpretations of what was needed. So far as technician certification in states, whichever regulations are more stringent will be what state surveyors surveying dialysis clinics will expect to see.
So far as to nurses vs. technicians, technicians can be very good at dialysis because that is what they’ve been taught. However, they may not do as well as an RNs in assessing and troubleshooting problems because they don’t have the years of nursing education that RNs have received. Here’s a renal career fact sheet on nephrology nursing from the NKF:
http://www.kidney.org/professionals/CNNT/nurscnnt.cfm
Certification is available for nurses. Dialysis clinics can encourage more nurses and technicians to be certified by helping with the cost of obtaining the certification and paying more for certified personnel. Here are a couple of the certifying agencies for nurses and technicians:
http://www.nncc-exam.org/
http://www.bonent.org/[/QUOTE]
When you say that state efforts to require certification led providers to support cert. in their comments, what were those state efforts? Are you referring to the few states who have passed laws for cert. or do you mean that the states spoke up for cert. in the comments or to the providers?
You would think that nurses having years of nursing education would be superior to techs at assessing and troubleshooting problems, but not necessarily. No matter how much other nursing ed. a nurse has had, it is not the same as dialysis knowledge. Knowledge of dialysis is the key and few nurses or techs seem to ever study the subject beyond what they get on the job.
If they do not get sufficient ed. on the job, then they get into patterns of poor delivery of care. Educated patients often know dialysis info that nurses and techs are unaware of. Amongst nurses and techs, there is also two types- the type who just shows up for work to get a pay check and the type who has a passion for dialysis and is ever increasing ones knowledge base. In clinics I have been in, the exceptional nurses/techs are the exception to the rule.
If a nurse is the exceptional type, then one might say her years of nursing education are an added benefit. But if she is the ho hum let me get my pay check type, her assessment and trouble shooting skills may not be so hot. It is surprising to me that some nurses even made it through nursing school. They must have pretty good memorization skills for test taking to have gotten a license, because they do such a poor job at nursing.
So my point is, anyone who works on dialysis patients, whether they are RNs with longer years of nursing ed., the LPNs with their 2 yr. degrees, or high school/G.E.D. level techs, should have a serious certification in dialysis. No matter how much nursing ed. one has had, dialysis is a specialty requiring background knowledge of kidney disease and very specific skills in order to carry out txs. Clinics “should” hire the certified nurses and techs and pay them more, but do they? Sounds like when you worked in dialysis, you were affiliated with one of the better clinics. But what I have experienced as a patient is a rag tag team of nurses and techs with an anything goes philosophy of care.
Almost every nurse and tech I have encountered was a hard working person. Given the right management and leadership from their superiors, the providers, I have no doubt they could of done a quality job. Even should it pass that both techs AND nurses have to be certified, providers still set the tone. Who hasn’t read the provider ads with the glowing words of their quality service and care? In too many clinics that is bunk- nothing more than a propaganda smokescreen! This industry has gotten a free ride for a long time. It is nice to see national tech certification at last. Surely it will prevent injuries and save lives. All the patient advocates who spoke up during the comment period and who work tirelessly for patient care deserve everyones’ wholehearted thanks and appreciation. Now, what about the providers?..seems they need a make-over…