This is a good question!
First: remember that while the home training unit (HTU) and the staff who work in it is dedicated to the concept of training for and maintaining in the home, it is, when it comes down to it, a facility. Not, mind you, a facility that operates under the common perception of a facility - the ‘have it done unto me’ approach - but, a facility none-the-less.
If a patient in a ‘standard’ facility were too ill to attend the facility, you would expect (as would I) that they would need at least brief admission to a hospital in order to restore a sufficiently robust level of health sufficient to allow their return to their routine ‘travel and be done unto’ 3 x week conventional program at a free-standing, non-hospital-based dialysis unit - ie: a return to facility-based dialysis … yes?
Importantly however, our HTU is set up to provide ‘respite’ care for those of our home patients who need it. This may be to help home patients over cannulation difficulties, or minor illnesses, or family issues at home. For this, they must travel to and from the HTU (just as a conventional facility-based patient must do … but for ever) at least for the period of time required to solve their home issue.
This, clearly, would be no different to any patient having to attend a facility-based program 3 x week (except we always ‘respite’ in the HTU at a minimum 4 x week).
If a home-based patient is too ill to self cannulate, we would treat that in exactly the same way - with HTU support through the illness … but we bring the patient back to the HTU and not to a facility service. For that period, the patient is, in effect, no different to a facility-based outpatient … as are most dialysis patients in western countries.
But, just as if a facility-based patient is too ill to attend their facility and (ergo) they are admitted, then if a home-based patient is too ill to travel to and from the HTU (in effect, then a short term facility providing respite), that patient would be admitted to hospital too.
On discharge, the ‘respite’ process at the HTU may also be used to provide a re-training or caring ‘bridge’ to home if the patient is unable to immediately return to self-care.
The issue is to ensure that there is a sufficient ‘respite’ capacity in the HTU … ie: spare and dedicated respite chairs. So far, we have managed to achieve that, though admittedly, it has strained us on occasion - especially as the size of the home program has expanded.
The trickier problem … and one for which I have no right answer … is ‘how to shake loose a home patient from the home’ if we think, through the efflux of time and/or illness, that the patient is now no longer safe to continue to dialyse at home. This is a problem we have discussed, often, nationally and locally … and we have had to face once or twice. It can be a very difficult process to negotiate. All I can say is that we ‘negotiate’ this on an individual basis … and it is never an easy task. I have to say that we find it easier to get patients home and sustain them at home than to get them back again!
To assist in this potential ‘down the track’ loosening process, part of the training for home should be training/educating/advising for the time if and/or when ‘home’ may no longer be a tenable prospect. This can be a hard sell, as once patients get home to self-reliance and self-esteem, that can be a strong bond to shake.
It is akin to telling an older person that they are no longer safe to drive a car and that their driving license is therefore to be revoked. As you know, this can be a devastating realisation to an elderly citizen who, rightly, feels that removal of their right to drive also removes their independence … and it does! A similar bombshell is dropped, when telling a home dialysis patient that, from now, it’s going to have to be facility-based care because we think they are no longer safe at home. Just like the elderly driver, they (and their families) rarely agree. For the patient, its loss of trust and loss of independence: for the family, it is car-pooling, and expense, and dependence. It’s never easy.
This is why it is so hard to get a system to commit to home care - though in Australia we are blessed with a system that does. For the dialysis team, it is so much easier to turn to production-line dialysis (a la Henry Ford’s Model T), send the patient down the street where a whole lot of arms can be held out, where patients can be done unto and, at the same time, shift the burden of costs and the responsibilities for transport onto families and others … oh, and look the other way.