PD Vs homehemo

Hi Folks

I’ve searched the pages here and did not see anything on PD and center trips on a monthly vs home hemo and center trips on a monthly.
Do people on PD have to draw own blood and go a center and have a three people read the same lab report, as do the home hemo people do?
bobeleanor :?:

I’m not on PD but my clinic obviously offers it. PD people actually have to go in an additional time to get blood drawn as they cannot draw their own. They go in get the blood drawn and then come back for their monthly appointment. My labs are “interpreted” by the dietician, nurse and neph. I find it strangely amusing the different comments by the different professionals and feel I get a better understanding of everything by their different perspectives.

Two appointments a month just doesn’t seem that bad to me to avoid having to go into center 3 times a week.

Cathy

All home dialysis patients (PD or HHD) are asked to come to clinic at least once a month. This helps to make sure that their nephrologist and clinic is following them closely enough to spot problems that might have arisen since the last time they were seen. Coming to clinic is also the patient’s opportunity to also ask questions of any of the team members and to participate in the team care planning meeting where goals and interventions are discussed. A nephrologist provides better care for patients when he/she receives input from each member of the team and from the patient, each of whom has a different perspective. Each member of the team is like a different piece of a puzzle. When a team is working well, all the pieces fit together to bring better care to the patient.

Over at “WellBound” I have 2 monthly visits, one at the clinic and another with the Nephrologist…at the same time while at clinic we’re also given opportunity to meet together along with Nephrologist and staff to discuss any concerns…

Cathy, Two visits a month wouldn’t be bad but you have to consider the distance some patients drive to be in a home program. You also need to take into consideration how many other appointments the patient has to deal with per month. In the Northern States I think one would need to be aware of the weather conditions. Not every patients has the same circumstances and most do so well 2 trips a month isn’t really needed.
We only do 1 visit per month but our labs are gone over by everyone before our clinic visit. Once we get there the SW comes and ask if we have any needs or questions. The dietitian comes and hands us our lab papers and asks if we have any questions then we see the nurse and nephrologist together. All together the SW and dietitian don’t spend 5 minutes with us unless we have a question or want to go over something. However, we know they are definitely available if needed.
Many a time we get called by our nurse at home once the center has gone over our labs to adjust EPO or something before it is actually time for our clinic visit. Also they are always available for us to call.
I think the best solution would be to work out an arrangement based on the patients circumstances.

Marty, generally most people go to their clinic one time a month, and that is it. My trip used to take nearly an hour each way, they have since opened another unit which is closer so now takes about 40 minutes.

My neph is not with the center so I visit him approximately every 6 weeks, he is about 20 minutes away.

The original question seemed to indicate that maybe there would be fewer visits with PD, my response was clear that it probably meant more visits.

I’ll stick with my 2 appts a month being better than 3 a week (on top of all other appointments) in center, and dealing with weather, holidays, outages etc. that come along with in center dialysis. Obviously if you can find a center that doesn’t make you come in monthly, great, I do believe that for most of us telephone consults are sufficient, but again, due to requirements, they probably aren’t allowed to do this, so I live with the appointment once a month.

Cathy

Hi Folks

Sorry, I did not look on the home page of this site I have not had the need really to do so. After I posted I went to home and answer the question. Thanks for the input.
bobeleanor :oops:

Bobeleanor, I don’t think there is any scenario where a dialysis patients labs aren’t gone over by the team. But there are places where the team meets prior to the clinic visit so once the patients come for a clinic visit everyone is prepared to meet with them at that time and they aren’t expected to make two trips. I prefer the one trip approach for 2 reasons.

  1. It’s one less appointment per month. 2. If I get information from the SW or Dietitian and it doesn’t jive with what the nurse or nephrologist are telling me we are all there at the same time to figure out why I think I am getting 2 different answers. More than likely I misunderstood someone but its nice to get it straightened out when everyone is available to get get together. I feel alot more secure in the fact I am getting the correct answers when everyone is there face to face rather than having someone relay information or questions for me.

Marty, generally most people go to their clinic one time a month, and that is it. My trip used to take nearly an hour each way, they have since opened another unit which is closer so now takes about 40 minutes.

My neph is not with the center so I visit him approximately every 6 weeks, he is about 20 minutes away.

The original question seemed to indicate that maybe there would be fewer visits with PD, my response was clear that it probably meant more visits.

I’ll stick with my 2 appts a month being better than 3 a week (on top of all other appointments) in center, and dealing with weather, holidays, outages etc. that come along with in center dialysis. Obviously if you can find a center that doesn’t make you come in monthly, great, I do believe that for most of us telephone consults are sufficient, but again, due to requirements, they probably aren’t allowed to do this, so I live with the appointment once a month.

Cathy

I am totaly baffled about this reluctance to go in to the clinic. I don’t give myself my epo, so I drop by twice a week for my epo shots. I also have one clinic appointment a month. I find comfort in going in so often. I can not imagine just not going in for months. How do you know how you are doing? Sure I have a better gauge of my body then anyone else, but I can tell you that High potassium sneaks up on you. So you at least would have to get labs done once a month. With PD you don’t have a blood access, so you would have to go in for that. I usualy only hear from one person about my labs though. having to listen to three people tell me just about the same stuff, ARGH!. Also I know what my labs mean and I don’t realy need to be told anything about them. Still I want my nurse to say thing look good or bad and why. It seems that in the Home Hemo world there is an attempt to get away from the medical world. Sorry, but we have kidney failure. We are stuck with the medical world. No level of denial can change that. If your clinic is a long distance away, maybe it’s time to move or get over having to drive or ride a bus. I have riden a bus three hours just to get to dialysis at a center I liked. That is six hours on a transit bus three days a week. I did it untill I could move to a place closer to the clinic. I complained a little, but I did it and I dealt with it. Going in to clinic once or twice a month is just part of the package.
LSB

Hi Folks

I just wanted to know if they was a big diffence in the types of dialysis. Did the types of pd permit people more freedom from center trips. And if you saw my last post I did see that pd did have people going into centers.

LSB. It is a your call thing or it should be, I have a chronic illness since birth. And the doctors I worked with up till dialysis have understood that they can not watch me 24/7. The doctors understood they had to empower me to take control of my life. If I screwed up I screwed up. If the problem could be fixed they fixed it. If I ended up in ICU so be it, but in doing so I learned . I’m use to working with just the doctor.

You and others on this page find comfort in seeing your team how ever many times a month as you want, and that fine. At no matter what the cost$$ it puts on the system. For me I just want the doctor and myself to make the call, and that should be fine too. This is the USA. If my center trips were at the same center where the whole team could talk to me and the center was just 20 miles away and I just had to do this once a month maybe I would say the same. But I draw my own blood I fax my flow sheets I understand the renal diet. In the event of needing 911 who do I call , my nurse 50 miles away, who trained me to get to the hospital where my doctor is asap. Getting the whole thing to a point is going to take time, I have or at least I want to have a life outside of dialysis. I have a doctor who seems to understand and seems to want the same thing. On the other hand davita seems to think that they are judge, jury and executioner. Over the last 10 months davita has opened it’s mouth and stuck it foot in, at least here in pa.

Marty seems to understand . I have nothing but respect for each person and the choice they make in the handleing of their health issuses. I want the same
bobeleanor :smiley:

Hi y’all,
Bobeleanor wrote:

Sorry, I did not look on the home page of this site I have not had the need really to do so. After I posted I went to home and answer the question.

Just wanted to remind folks that we have TONS of content on this site that isn’t in the message boards, including:
Descriptions of the 5 types of home dialysis http://www.homedialysis.org/v1/types/
Topic of the month articles http://www.homedialysis.org/v1/news/#tom
Dialysis equipment (includes our Virtual Dialysis Museum) http://www.homedialysis.org/v1/equipment/
Find a center database http://www.homedialysis.org/v1/hpc/catalog.shtml and coverage maps of where you can find each type of treatment http://www.homedialysis.org/v1/types/maps.shtml
Stories of people using each home option http://www.homedialysis.org/v1/profiles/
Our Legislative Action Center where you can write to your representative–or the media http://capwiz.com/meiresearch/home/
Sign up for our free, monthly eNewsletter http://capwiz.com/meiresearch/mlm/signup/
A zillion links, in useful categories http://www.homedialysis.org/v1/links/
Professional resources, like slide kits and Medicare FAQs http://www.homedialysis.org/v1/resources/
Info on how to start a home program–including our Consultant’s Corner http://www.homedialysis.org/v1/start-a-program/
About Home Dialysis Central–who we are and why we started the site http://www.homedialysis.org/v1/about/
Order free postcards http://www.homedialysis.org/v1/contact/postcardsForm.shtml
And, of course, how to support our efforts and help spread the word about home therapies http://www.homedialysis.org/v1/support

Browse around a bit–you’ll learn a lot!

LSB it isn’t a reluctance to go to the clinic. The reluctance comes in when you have to travel a distance to get there. I am fortunate in the clinic I go to the nephrologist visit is in conjuction with the clinic visit. We have made all of our clinic visits which include the nephrologist and it is 500 miles round trip. Don’t you think if I had to go 500 miles for clinic then 500 miles for a nephrology visit then 500 miles for EPO or iron or to take in labs it would be a bit much.
Cathy in our area it must be different than in yours. If your in a home program in our area you are required to meet with the nephrologist who is connected with the clinic you are in. Therefore if the clinic visit is 50 miles so is the nephrology visit and so far no one gets with seeing the nephrologist 4 to 6 weeks. It is usually 4 weeks unless he is on vacation.
I would agree 50 miles twice a month is better than 3x a week but for whatever personal reasons dialyzors have no one in our area is convinced.

We feel once per month is sufficient for the purpose of seeing the doctor. In our program there is no such thing as meeting with the team. Does anyone know what the Medicare regulations say about who should be present when home patients come in for the monthly meeting? Our unit is the same way whether one is in-center or in the home program. There is also no meeting of the team inclusive of the patient when it comes to care plans.

The question is, WHY is it this way? Is it easier for the unit not to have the team meet at one time with the patient? Are they spread so thin that they can’t afford the time to all get together with the patient? Do they see this as a waste of their time? Obviously, the patient would benefit far more if the entire team met with the patient and each put forth their expertise for the patient’s benefit. But in units like ours this does not occur. Maybe it comes back to the attitude that educating patients and including them in the care team is not the primary concern- it’s just manage them and push them through.

Unless we are missing something, it seems that the respect patients are afforded, in this case home patients. depends upon the values of those in charge. Another thing we’ve noticed in units we’ve been in, is everyone seems to defer to the nephrologist. If everyone did meet with the patient as a team, I don’t know if anyone would get in a word edgewise as the professionals often don’t act very professional in that everyone watches what they say around the doctor and you don’t see a truly free exhange of information. Yes, the doctor is the most learned in one sense and should be esteemed, but if the other members of the team are learned in their respective areas, they should have valuble insights, too.

So, just how educated are the other team members on ESRD and WHAT prevents them from acting as a team? We’ve had some dietitians that were so up on ESRD that the nephs often deferred to them. Then we’ve had others who are newbies…same with SWs and the RNs. But either way, we’d like to meet with our entire team, but never have. Doesn’t it come down to management, leadership and professionalism? One good meeting a month with the entire team present and respect all the way around would be what we’d like.

Two barriers that keep the team from meeting together with the patient include scheduling a time that works for everyone AND the impression that staff have that patients aren’t interested. Some clinics routinely invite patients to attend care planning meetings and most say patients do not choose to attend. I don’t know if that’s because they’re not informed about why they should be interested in attending or if the timing of the meeting doesn’t fit with their schedules. So far as staff are concerned, there are a limited number of hours in a month and although the home training nurse may stay at the one clinic, many dietitians and social workers cover multiple clinics and doctors have office hours, see patients in the hospital, and have to make rounds in multiple clinics where they have patients.

The ESRD Conditions for Coverage defines the team that is to be involved in care planning and names the physician director, nurse, social worker, dietitian and it even states that the director of a self-care training clinic and transplant surgeon. The assumption is that the team will meet as a group to discuss patient status from all perspectives – which seems to happen less and less. Surveyors look at care planning and how it’s done, including how the patient is involved.

BTW, about deferring to doctors…Doctors have their area of expertise, but they are not deferred to nowadays as they may have been in the past by past generations. Doctors have the most education of all dialysis staff. However, after the doctor, the masters prepared social worker (what clinics should have) is the next most highly educated staff in the dialysis clinic with 6 years of post-secondary education. When I attended care plan meetings (we had them as a team), I said what needed to be said to advocate for my patients when they weren’t there. I would have preferred them to attend to advocate for themselves. I hope they would have felt confident enough to state their opinion, even if it differed from the doctor or other staff.

I need to make an apology here. I opened my mouth and inserted foot. Where I live there are tons of clinics. I can not imagine living over more then an hour away from a clinic. There was a time when I lived a three hour transit bus ride away from the clinic I liked. I could’ve easily moved to a clinic closer, but I don’t get along with most doctors or nurses. I suspect that most of the people on this board are not unlike me in that matter. This thread just struck a nerve. At my clinic that I am at now, there are patients that dread coming in for their monthly visits. They just don’t want to work within the system they are in. They are on PD and have to come in for lab draws. If they were on Home Hemo then they could that themselves. In the wash, we all are probably somewhere on the same page. It’s just we can’t see each other cause the print is so big.
Bob;
I would say you got it as free as you could get it. Start taking a voice recorder to whenever you talk with Davita. Record everything they say, then you can make a case against their practices. I personaly hate Davita, they could be some realy jacka$$ people at times. All of these companies are for profit, so you as a patient mean very little to them.
I wish you the very best and hope that you are happy and healthy…
Peace;
LSB

Beth wrote:

Two barriers that keep the team from meeting together with the patient include scheduling a time that works for everyone AND the impression that staff have that patients aren’t interested. Some clinics routinely invite patients to attend care planning meetings and most say patients do not choose to attend. I don’t know if that’s because they’re not informed about why they should be interested in attending or if the timing of the meeting doesn’t fit with their schedules. So far as staff are concerned, there are a limited number of hours in a month and although the home training nurse may stay at the one clinic, many dietitians and social workers cover multiple clinics and doctors have office hours, see patients in the hospital, and have to make rounds in multiple clinics where they have patients.

The ESRD Conditions for Coverage defines the team that is to be involved in care planning and names the physician director, nurse, social worker, dietitian and it even states that the director of a self-care training clinic and transplant surgeon. The assumption is that the team will meet as a group to discuss patient status from all perspectives – which seems to happen less and less. Surveyors look at care planning and how it’s done, including how the patient is involved.

Beth as you said, there are clinics that routinely invite patients to attend careplan meetings. If they can do it seems other units could find a way. But it seems the bigger issue is the derogatory attitudes many professionals have towards patients. They seem to see all patients through the same lense. Because many, or most patients, are apathetic about their care, then all should be punished and no one should expect quality care. It’s ok to get lazy in the delivery of care, because after all, the patient"s" don’t care.

This, of course, is a ridiculous notion. Yes, in some units, if not most, the majority of patients are a real challenge to deal with. But the apathy and prejudicial attitudes that so many of the medical professionals have developed is not healthy. I honestly think they need counseling as they are at a loss for how to professionally deal with patients’ issues so take the path of leaste resistance.

Really and truly, we see all sorts of dysfunctional behaviors on the part of the professionals. They become exasperated with the dysfunctional patients and it becomes like the alcoholic and the enablers. And many medical people come to their careers with problems of their own which become accentuated in the workplace.

All of this has created a dialysis setting where the professionals manage patients health/lives without their input and nothing could be worse. I keep using the word “dysfuntional” as to me that is the best word to describe the situation. I fully realize that many, if not most dialysis patients, fail to take responsibility for their health, but I believe there are patients who would respond to mental health counseling and dialysis education if they were afforded same and were not labeled, their desires for care routinely disrespected.

Beth wrote:

BTW, about deferring to doctors…Doctors have their area of expertise, but they are not deferred to nowadays as they may have been in the past by past generations. Doctors have the most education of all dialysis staff. However, after the doctor, the masters prepared social worker (what clinics should have) is the next most highly educated staff in the dialysis clinic with 6 years of post-secondary education. When I attended care plan meetings (we had them as a team), I said what needed to be said to advocate for my patients when they weren’t there. I would have preferred them to attend to advocate for themselves. I hope they would have felt confident enough to state their opinion, even if it differed from the doctor or other staff.

Regarding doctors, I meant that in units we have been in, the other team members act rather mouse-like like they are walking on eggshells when the doctor is there. They tend to shut up and let the doctors do most of the talking. When the doctors aren’t there, they open up more and speak more freely. I’m sure this is not the case everywhere, but, unfortunately we have experienced it a lot in the particular units we’ve been in. I’m glad to hear that you advocated for your patients. We have had some wonderful nurses who absolutely advocated for their patients at the risk of their jobs. Patients in most of the type units we have been in know one better watch what one says in negotiation for one’s care or he might be kicked out. As has been said before, it can be devastating to get fired for speaking out, but one can get another job. It is far more serious to be asked to leave a dialysis unit to find care elsewhere.

I agree that patients should not feel threatened when they make reasonable requests or advocate for themselves. According to the Conditions for Coverage (ESRD regulations):

i Standard: grievance mechanism. All patients are encouraged and assisted to understand and exercise their rights. Grievances and recommended changes in policies and services may be addressed to facility staff, administration, the network organization, and agencies or regulatory bodies with jurisdiction over the facility, through any representative of the patient’s choice, without restraint or interference, and without fear of discrimination or reprisal.[/i]

This is a standard under the Condition Patient Rights and Responsibilities. Dialysis clinics can, and in my opinion should, be cited by the survey agency if patients feel that their clinic will kick them out or in some other way discriminate against them if they complain either internally within the clinic or externally to the ESRD network or state survey agency.

I run a PD program. I request that my patients come in at least a week prior to the monthly clinic visit for blood work so the values are currrent and available for the TEAM to review at the clinic visit. On clinic day all members of the team - nutritionist, social worker, the physician and myself meet with the patient and whomever comes with them. Several of my patients that don’t want to give themselves EPO come weekly to see me for the shot. Actually patients prefer to come for their blooddraw prior to the CV, and don’t ever offer a complaint. It only takes 10 minutes. If they have a transportation problem, then I draw their blood at the CV - I ask them to come alittle earlier. It is a given that we all make time in our schedules to be available that day, as the beauty of home dialysis is independence and we accommodate. We all collaborate during our meeting. I am usually with the patient when the MD does his assessment, and the patients meet individually with the SW & RD while waiting. I often run the Clinic Visits as I keep in close contact with the patients during the month as needed and keep the meeting focused on issues. Regulations require the patients come in center once monthly. Even if regs didn’t preclude this, I like to see the patient and validate their weight, review their exchange schedules, assess them physically for proper EDW, check their exit sites, do med reviews, change their extension set, etc. My job is to provide support. They never complain. I don’t think I would feel I was doing my best if I didn’t see them AT LEAST monthly. From experience you can pick up subtle changes in patient by doing a thorough assessment. I don’t see what the big deal is. I guess in rural areas it may be a problem, however.

Jersey Girl, I am the one who most often speaks of patients living in a rural area or country. In our area there are several small towns and the population is also small. Therefore we only have a couple of diaysis centers and they aren’t very large. These facilities don’t have home hemo programs.
However, if you can and are willing to travel you can find a program in one of the closest cities which is about 60 to 100 miles away. The patients I have spoken with can accept the traveling for training, and they expect to have to go and see the staff at least once a month. The problem for these dialyzors is when the trip becomes more than once a month. It’s sounds as though you do try to work with the patients, congrats! However, not everyone does. If the patients in the country, go to the city to get into a home hemo program they are asked to make 1 clinic visit, 1 nephrologist visit,
1 or 2 trips for iron if iron is required. The idea of possibly taking on a long trip up to once a week so far has discouraged them from home hemo.