Wellbound

I was wondering why this wouldn’t work. What if I, and a nurse decided to start a home hemo program. Suppose we could get a nephrologist and a center to back us up. It seems as though everyone around here is afraid of loosing money so if I put up the money to start the program and approached a center and nephrologist and said. If you will take my patients as their nephrologist and the center or hospital can have the reimbursement for nephrology, and in-center treatments, and whatever else is required why is this such a dumb idea. Is this along the lines of what WellBound does or do they have their own centers.

Actually Wellbound, although dedicated only to home dialysis, is owned by Satellite Dialysis Centers which is an incenter dialysis group. I know that Wellbound needs to have its own medical director (doctor), you need a social worker and dietician, etc. It sounds good but you really probably need a center to “sponsor” you. What might be more effective is to get a few patients in the area who would want to do home dialysis, or find a home unit that offers pd and see if they would add hemo, and offer to do the leg work etc. to help them get started.

Cathy

Cathy,

I have been trying it your way for over 5 years. It doesn’t work. The excuse is money, money, money. I have reached a point where I think NxStage will catch on and am willing to invest my own money to start a program. It’s as hard to get information on how to start a center as it is to get a home program. Wellbound ads say they partner with nephrologist. Guess I don’t
know what this entails.

You can read about how to start a program and talk briefly to any of the consultants willing to help people do this. Links are at http://www.homedialysis.org/v1/start-a-program/

You can read about dialysis survey procedures at http://www.cms.hhs.gov/GuidanceforLawsAndRegulations/05_Dialysis.asp. From this page, follow the link below to the surveyors’ guidelines for how to survey a dialysis clinic and the ESRD regulations that clinics operate under http://www.cms.hhs.gov/manuals/downloads/som107ap_h_esrd.pdf

Some states have a process called “certificate of need” where you have to prove that another dialysis provider is needed. Your ESRD Network should know if that’s required in your state.
http://www.esrdnetworks.org (click on your state on the map)

I don’t know what the financial investment is to start a dialysis clinic but believe it is considerable. I’m not sure what it would cost if you did only home dialysis training and support. If you didn’t have an in-center clinic, you’d have to have an arrangement with one or more clinics to offer in-center dialysis as a backup when needed. You’d also need arrangements with a hospital to admit your patients. You might want to read this article from 1997 by Katrina Russell, one of the consultants in our consultants’ corner:
http://www.eneph.com/feature_archive/Peritoneal/v26n2p96.html

Beth, Thanks for the references. I know the investment would be considerable but I think the NxStage is really going to pay off. The Rubin hasn’t had anywhere near as much trouble getting home patients with the NxStage as they did for nocturnal and right now they are training all their PD Nurses to train patients on the NxStage. It looks as though they believe in its growth as that will be 5 nurses capable of training patients at any given time.

Why are they training PD nurses to become the trainers for NxStage rather than HD nurses? Most PD nurses we have known have no experience in HD.

Most dialysis nurses I know have said that it was quite a challenge to learn hemodialysis. I worry a bit that commercial interests may lower standards for home hemodialysis to the point that a few well-publicized deaths will put the kibosh on the whole concept of home hemodialysis.
Pierre

I am just taking a logical guess here. The more trainers they have the more patients they can train in a shorter length of time. I believe one could think as time goes on there will be a decline in PD because patients can now travel with the NxStage and the training time is 1/2 of what it was for the other home hemo machines. I also think they realize PD nurses can be taught about hemo. Why would you go out and hire more nurses when you already have PD nurses with spare time that you can teach. The basic concepts of dialysis remain the same and the PD nurses have this. I don’t post this as a truth. I post this as my opinion and when it comes to understanding why and how centers react I have no authority at all to be mouthing off.

Pierre, I don’t doubt for a moment what you have said. But the PD nurses we have, have all worked in-center at one time or another as have the Hemo training nurses so I don’t think they are lacking in experience to hemo.

Heather, they have HD Nurses already training patients it’s just a way of getting more HD nurses. You cross train within or go outside and hire.

Every clinic that I’ve worked in – and I’ve worked in 3 – has had one or more nurses that trained patients on both PD and HHD. In my experience, PD nurses often choose to learn PD after doing HD. They learn the PD procedure and learn how to teach patients how to do it. To have a certified training program, the nurse in charge of a self-care training program has to not only have nursing experience and experience in dialysis, but has to have at least 3 months of experience training patients. It’s hard to get the 3 months training experience if you work in an in-center HD program. Nurses (PD or HHD) who train patients for home hemo are trained by the company that makes the machine to train patients on it.

It seems extremly logical to me to use the PD nurses to do HHD training too. This expands the number of staff that can train patients so patients can get into home training sooner (I’ve heard of 1-year waiting lists in some areas of the U.S.). Finally, in-center HD nurses may underestimate patient’s interest and abilities, assume total control, and refuse to let patients touch (or sometimes even look at) the HD machines keeping them dependent. However, PD nurses are comfortable educating and empowering patients to assume maximum control over their health and treatment and get a lot of job satisfaction from watching their patients become self-sufficient.

All the PD nurses we have known enjoy teaching PD, because they see the benefits of empowering the patients to become self-sufficient. They are very good at what they teach- PD. Just as the patients can be quickly trained on Nxstage, the PD nurses can, minially speaking, be trained to train the patients. But like Pierre, I have my concerns, because how is a nurse who is unfamiliar with the ins and outs of HD suddenly supposed to be competent enough to train patients and know how to guide them when they have tx issues at home in the middle of the night? The majority of the nurses and techs we see in-center get into problems all the time and have to call on the more experienced nurses to bail them out. So, whereas this is an economic plus for the companies, is it safe? Does it really comply with the Medicare regulations? Will the PD nurse have to say to the home patient, “Can you hang on for a minute?” and then go running to an experienced HD nurse for what to answer the patient? And remember, the experienced HD nurse won’t be there on 24 hour call.

Jane, You have made way to many assumptions. You are assuming that they are going to throw PD nurses into training patients without giving them the knowledge to handle the job and this just isn’t so. You also assume their won’t be anyone to call but in our program there is always someone up the line available to take a call. Since day 1 we have had techs monitoring us at home who haven’t even set up a machine. And yes calling someone else is exactly what they do. Sometimes they can solve the problem or answer the question, sometimes they call a nurse, sometimes they call the machine techs.

Marty writes:

Jane, You have made way to many assumptions. You are assuming that they are going to throw PD nurses into training patients without giving them the knowledge to handle the job and this just isn’t so.

Not assuming anything, Marty. A PD nurse can be given good training in order to train home patients and certainly that is positive. But good training is not the same thing as experience in HD. So, perhaps they will have experienced HD nurses PD nurses can confer with? But they would have to have a tight system here or it could be a hazard waiting to happen as Pierre suggested.

Marty writes:

You also assume their won’t be anyone to call but in our program there is always someone up the line available to take a call. Since day 1 we have had techs monitoring us at home who haven’t even set up a machine. And yes calling someone else is exactly what they do. Sometimes they can solve the problem or answer the question, sometimes they call a nurse, sometimes they call the machine techs.

I am surprised to hear that techs who have never even set up a machine man the phones! But I see what you mean that they sort of screen the calls and if they can’t solve the problem they call an experienced nurse or machine tech who is on call for the evening. Again, problems can occur fast so I hope this system is fast enough thus safe.

Problems occuring fast. You have to know the machine shuts down when it is a machine problem so the patient isn’t at risk. One time dad had a severe case of diahrea which caused him to go hypotensive. I didn’t even call the center I called 911. Then I called center to tell them we were on our way to the hospital. I can handle giving saline for low BP but I knew this was beyond that. You also have to keep in mind all of the PD nurses work in-center with hemodialysis patients during slack times or when their is a shortage of staff.

Let’s put it this way-what situations have home patients had to call the on call person for? Because the patient and/or home tech should be so well trained that they are prepared for every eventuality.

Re PD nurses, I have known some who know both PD and HD, but I know others who are strictly PD, have never cannulated a patient or run a HD tx.

I found that there are surprisinly few reasons to call the on-call nurse. I’ve only had to call when setting up because something like conductivity was beyond the limits or the machine didn’t pass the alarm test (my instruction say to call in such cases). If there is a medical emergency, I would call 9-1-1 right away and bypass the nurse. Once you learn the little tricks for dealing with minor setup problems, you know and you can handle it without calling. Personally, I don’t think there would be much point in being trained by and having an on-call nurse who has little more experience with the machine than I do. Tech problems requiring repair or adjustment of the machine aren’t done during the night anyway, so for that, there’s no point in calling until the morning.
Pierre

Pierre, I agree with you, there isn’t much reason to call a nurse. The only time I have talked with a machine tech is when my conductivity was going out of limit at 13.9 they told me how to change it so that I wouldn’t get alarms until it was past 14.0. Were talking about 6 years here and I have only talked to a nurse about once. One night I was having trouble with dad’s “new cath clotting” and she told me how much heparin to use in the lines and how long to let it dwell.

Jane, It seems to me you don’t have much background on doing home hemo, and your imagining things. The patient and the home tech should be so well trained they are prepared for anything is not a thought out statement. There is no way you can be 100% at every little thing all the time. We were taught how to rid the system of air. This is something I have never had to do in 6 years so if I had to do it tomorrow, I wouldn’t be the most efficient person on the block but I could get it done. So what if you know PD nurses who have never run a treatment or cannulated a person. If they cross train they are certainly going to learn those things just like the home patients do. To think a unit would have home patients and those unit would be careless enough not to be safe is just a bit ridiculous. We get more individual attention if needed, than any in-center patient as our support team is not looking after more than 1 person at a time.

Pierre writes:

I found that there are surprisinly few reasons to call the on-call nurse.

Good to know your training is so complete.

Pierre writes

Personally, I don’t think there would be much point in being trained by and having an on-call nurse who has little more experience with the machine than I do.

I agree.

Wouldn’t make much sense for the centers either to have taining nurses or on-call nurses that didn’t know more than patients which is probably why we have never heard of a case where this is done. If I were training to be a home patient and I didn’t feel absolutely sure the nurse knew more than I did, and alot more than I did… I’d get out.