What has prevented the growth of home programs?

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Recommend (1 recommendation so far) Message 33 of 34 in Discussion

From: Dialysis Joe in response to Message 32 Sent: 5/26/2006 2:21 PM
Angie and Jeff,

Just caught the tail end of your home dialysis discusion and thought you’d like to know that it’s cheaper, in the long run, to have patients on home hemodialysis. The single largest cost of doing any business is staffing. This is no different in the dialysis facility. You can have one nurse oversee the care of 30 home dialysis patients. In center dialysis is simply more staff intensive. This is why American providers are looking to home dialysis to offset the anticipated reductions in dialysis reimbursement due to “The Deficit Reduction Act.”
The reason that most facilities are not active in home hemodialysis is pure laziness on the part of physicians and renal administrators. The majority don’t want to put forth that initial effort to get their programs up and going. This is very un-businesslike, considering the savings in staff costs that come from doing home hemodialysis.
One other issue is being able to give up control over a patient. Many professionals are threatened by patients that have knowledge and know how to handle their own care. Frankly, this may be one of the biggest reasons holding back home hemodialysis.

For some nephrologist, they just don’t feel patients have the intelligence to do home dialysis. What they forget, or if they are new in the business, and never learned, is that hemodialysis and peritoneal dialysis began in the home. In the beginning, there were very few facilities and patients, if they wanted to live, had to dialyze themselves in the home.

Joe Atkins
In Canada, home dialysis makes a lot of sense, just as it does in the United States.

Although I’d love to have one thing to blame because if there was one thing that inhibited the growth in home hemo, it could be fixed pretty easily even if it was attitudes. In truth I suspect this is a multifactorial problem and one that hasn’t been studied enough to know why programs weren’t growing for so many years.

HHD is cheaper than in-center HD in the long run. However, there is significant expense in starting a program, developing manuals, having the appropriate staff, obtaining equipment and supplies, etc. One home training nurse can take care of 15-20 patients. However, if you only have one nurse training patients and he/she trains 1 HHD patient every 6 weeks, a clinic can only train a small number of patients a year.

To keep a nurse busy, many also train PD patients. Scheduling PD training limits the time a nurse can train HHD patients. When Medicare reimburses a clinic for PD training, the clinic gets the daily HD rate which is more than twice the PD daily rate plus $12. Plus PD patients go home in 1-2 weeks and start being cost effective sooner.

The clinic training an HD patient gets the HD daily rate which has not been adjusted for inflation since 1983 plus a $20 add-on per day to pay for training manuals, training supplies and the nurse’s time. The HD daily rate has a labor component that assumes a nurse is taking care of several patients. An HHD training nurse takes care of one patient. So…bottom line…clinics make more money training PD patients, even those with Medicare, and lose a lot of money training HHD patients with Medicare. I don’t know if anyone has presented this to Congress in quite this way, but the more I think about it, there needs to be a change in how Medicare reimburses training to incentivize more clinics to do it because of the original outlay until a program has 20 or more patients.

At Medical Education Institute we can’t make Medicare pay more for training, although we share what we believe about policies that are barriers. MEI developed Home Dialysis Central because patients can’t ask ask for HHD if they don’t know it exists and staff without HHD experience don’t realize how much they are fostering dependency by telling patients they need “professionals” to do complex medical treatments. Anyone reading this board can see that all of you have become “professionals” in taking care of your body and doing your own treatments. I believe a patient and caregiver who are motivated to learn HHD can become as “professional” as a well trained technician.

We can learn from the past and set goals for the future. However, we need to live in the present and help more people know where to find HHD programs. I anticipate that when clinics start losing patients to their competition, some will reconsider adding HHD training programs.

I don’t think your going to see a big influx of home programs until Nephrologist and the government decide that it’s important patients have better dialysis. Quite frankly, what I see now is… if the patient is alive that is
good enough.

If you have the money to start a program, to keep up with the competition then you had the money all along and just chose to keep it rather than putting it into a program for patients.

The bottom line is most of the persons who have the power to make changes to benefit patients just care more about the $$$ and work they have to do than the patient. Nocturnal was started in Canada by a Nephrologist determined and committed to patients. It was brought to the U.S. by Nephrologist who were determined and committed to patients and programs usually start when someone becomes determined and committed to patients.

I believe cost is involved but the real deal maker or breaker is ones committment to the patients. Our center has known for over a year the financial cost of starting a program has been approved. To this day, the progress made toward starting the program has been minimal. Why? It surely isn’t the money factor that has been taken care of. The reason I hear is because we have been to busy to get things done. Although they say they are glad they can have a program to help the patients; I see nothing in terms of committment and determination to get it done for the patients.

If attitudes can be fixed pretty easily, I’d like to know how. Put the patient first and I think you would see amazing results and the money would follow.

For the centers that don’t have program or even area’s that don’t have programs I would have to ask

  1. Does anyone really care how healthy the patients are?
  2. Does anyone really care patients loose their job and livelihood from feeling poorly and not being able to work because of the dialysis schedule?
  3. Does anyone really care that patients have to travel sometimes over an hour to reach a center?
  4. Does anyone really care that patients are in-center away from their families when they could be in the comfort of their own home enjoying their family?
  5. Does anyone really care that in-center patients have to schedule their life around the treatment times instead of having the priviledge of scheduling the treatments around their life?

My gut feeling is we care but we care More about the money. If the patients were put first and more programs started it may even drum up
some incentive to create machines which required less training cutting cost, it may create and incentive to design machines that aren’t so costly in the first place. I would say at this time their is interest in making the technology better but if the proof was there that patients were going to be the first priority and patients were going to be given choices of HHD it would certainly make it easier for the companies developing machines to put more investment into it.

Sorry for the rant but when I hear the money story over and over again, I can appreciate considering the cost but it’s just putting the patient second.
If it were truly a world where we looked out for the patient why couldn’t some of the centers in an area pool together to start a home program, share the cost and share the profit when it became available. There are ways to deal with the money problem if we are determined and committed to doing what is right for the patient.

Forgot to add if were not to lazy to do it.

Whose decision is it to open home programs, corporate, the nephs, or both?

I wasn’t told it was available, and then I was told I was accepted and it was available, only to be shot down because I have my own and septic. The company is a major player in the Northeast where I live and supposedly offers home hemo to anyone who is deemed capable of taking on the challenge, however their brochures fail to mention that they (I’m sure not unlike otherss) pick and choose which pt. will save more money, or be more profitable to keep incenter. For me I needed newer technology and a unit willing to take it on.
I surfed the net, using the sites that are supposed to list units that offer home hemo but the minute I mentioned my situation was turned down again and again being told that “we aren’t taking on new pts” ect… The new unit I eventually transferred to didn’t offer it and weren’t at all hopefull they ever would. Now I’m told they are going to be starting a program. In addition because of my posting here a nurse who heads the program at unit who has an up and running program has offered to take me on if things don’t pan out. She’s within a few hrs. of my home! I would have never found this info. out if not for this site. It doesn’t really matter what has kept things from happening because the times are a changing. I think more units will start offering home hemo when they realize there is a population of pts. interested in it, and capable of taking care of themselves. After all if they can train techs they can train pts.!
This site plays an important part in bringing those desiring it, and those providing it together; the only way is up! Lin.

If I were to make an intelligent guess, I’d say whoever is going to finance it.

This board has been a tremendous help in getting home hemo out in the open. I do believe there is alot more discussion about daily and nocturnal dialysis. I do know there have been an increase in programs but I would hesitate to say it is on it’s way up. I think certain areas are growing toward home daily and nocturnal but if you look at the whole United States the growth rate is still very very small and not to impressive.

In my experience, it is a joint decision among the professional players: the corporation, the medical director, the administrator, and home training staff (if any). If any of them are opposed, some convincing needs to be done. To some extent, this is where patients come in. patients make decisions with their feet. The corporation, medical director, administrator, and home training staff need to understand that if they don’t offer treatments, patients may choose a different provider that does. When a patient is considering leaving a clinic because of better options elsewhere, he/she should make sure that these key people know that he/she will be leaving not because he/she was dissatisfied with care, but because the clinic did not offer the home treatment and/or machine that he/she wanted. It may take a few patients leaving, but eventually this have the most impact in getting corporations and/or clinics to offer more options to patients.

Who finances home programs?

A training nurse can only train ONE patient at a time? Why?

To me it looks like the Medical Universities, non-profit corporations, simply the medical research foundation are the only ones supporting home dialysis… there’s a good reason for that…


A training nurse can only train ONE patient at a time? Why?

Historically clinics have trained one at a time because different people learn at different paces. However, some clinics have had success training 2 or even 3 people at a time. I suspect the nurse trains all of them on certain things together and then allows those that get it to practice something at the same time he/she works individually with those that didn’t quite get the lesson. But I’d love to hear how group training is done from someone who was trained in a group.

To me it looks like the Medical Universities, non-profit corporations, simply the medical research foundation are the only ones supporting home dialysis… there’s a good reason for that…

We are seeing growth in clinics offering home hemo. This is true for clinics that are for-profit as well as non-profit.

Medicare does not reimburse for home hemodialysis done more frequently than 3 times a week without medical justification so more clinics offer conventional home hemo (344). More clinics are sticking their toes in the water with daily (102) and nocturnal (101) to see how their patients do. Some clinics that offer nocturnal home hemo offer it 3 times a week to deal with the reimbursement problem.

I’m sorry, I still don’t get it. We haven’t been for training yet. Does the training nurse train one patient for 8 hours a day, five days a week, for 6 to 8 weeks?

Most nurses train one patient at a time for 3-4 days a week for 4-6 weeks, depending on how quickly the patient learns. Sometimes a nurse trains more than one patient at a time, but from what I gather, when I’m at meetings and nurses say they train more than one, you can almost hear the shock go around the room.

I think there are definite advantages to training more than one person at a time as long as they learn at approximately the same speed. People can learn from watching each other and can give each other support.

However, if there’s too much difference between learning speeds, one person may feel pushed and another may feel held back. At the same time the nurse may feel torn by having to go over different lessons in the same room at the same time. It is kind of like being educated in a one room schoolhouse.

I think this weeks Weekly Feature pretty much sums up the attitude needed to create more home programs. WellBound Putting Wellness FIRST! This pretty much falls in line with my observation that the places who have started home programs have done so because they are committed to the wellness of the patient and all thought profit driven not to the extent that patients have to remain in-center to maximize the profit of treatments.

I am proud to say my clinic is Wellbound. They are simply wonderful. They do train only one patient at a time so they can really work with you and go at your speed. My nurses trained with me too, which was fun as we really got to know each other. They were very long time dialysis nurses, but didn’t know the particular machine I was using. Of course I had another training nurse training both of us.

They are opening home clinics across the country as fast as they can, but they do have extremely quality people and programs so it is hard for them to find the staff and then deal with the burocracy of getting permits etc. I know the State of CA is holding them up right now unable to send out someone to certify them at one location even though it is ready to go. It must be very frustrating for them (and me as it will cut off a ton of time when I can use that clinic).

home hemo 9/04

They just opened one up in Stockton…I’ve heard rumors that they will open one up soon in Texas somewhere…

Does the corp put up the financial investment for the machines or do nephs sometimes participate financially?

Jane, When I asked about that was told the machines will be leased not purchased. They will be using the Nxstage machines so I don’t know if leasing is a prosect with other machines/companies. If they don’t have to purchase machines there should be no real outlay, no real barrier (other than permitting ect. that it takes for starting a program) to units now offering home hemo programs. As to Medicare not paying for extra txs… I don’t see how that can be a deterrent either because it won’t cost more for staff ect. when a person is doing more txs. at home. I suppose they could do longer txs too if it were a question of using and paying for extra supplies for more txs… With the newer machines there also is no hookups/renovations required. The only reason we’re considering an addition is because we live in a ranch that is under 1000 sq. feet smalll lol With the Fresenius machine we would have other renvovations, electrical, plumbing, ro ect… that won’t be necessary now, so there won’t be added costs to us or the unit. Lin.