Transitional care units set patients up for successful dialysis
An interdisciplinary group of dialysis professionals is poised to launch a multicenter pilot project to gain further evidence of the efficacy of transitional dialysis care units. The project awaits IRB approval at two primary locations with a goal to start enrolling patients in April and May. Led by retired nephrologist Robert S. Lockridge Jr., MD, the pilot project will show a practical way to implement the group’s recently published operational guidance manual for transitional care units for dialysis. The goal of the manual is to have more patients experience the medical, emotional and educational benefits of transitional dialysis care units.
A transitional dialysis care (TDC) unit implemented according to the manual will offer a dedicated space for patients transitioning to dialysis and provide on-site treatment using home equipment, supplemented with thorough patient education on the psychosocial issues associated with dialysis, as well as nutrition and vascular access. The manual offers a sample curriculum for both education and intended outcomes.
Lockridge and colleagues hope the manual will assist providers in improving outcomes for patients on dialysis, including: eliminating the 2-day treatment gap, or “killer gap,” that occurs on weekends for in-center patients; creating consistent blood and dialysate flow rates with typical home hemodialysis (HHD) prescriptions; and reaching target weight and blood pressure goals by using more frequent HHD and low ultrafiltration (UF).
A critical transition
Lockridge, a longtime advocate for HHD, believes TDC units are the solution to improving outcomes for patients who are new to dialysis, as incident patients are at their highest level of risk for mortality and hospitalization.
“Even though we have improved outcomes of dialysis patients, in the first 90 days patients die [at a rate of] three-times greater than any other time in their dialysis experience. In the hospital, [the rate is] two-times greater than at any other time, and the leading cause of death is cardiovascular,” Lockridge said.
As a study recently published in the American Journal of Kidney Diseases showed, patients on dialysis have a higher mortality rate than patients with several common cancers, including prostate and colorectal among men, and breast and colorectal among women. With the dialysis population forecasted to increase by more than 3 million patients globally in the next 15 years, the researchers advocated for funding, development and testing of new interventions to improve survival.
Roughly 124,000 patients are new to dialysis each year, and about half of them do not know why their kidneys failed, Lockridge added. Additionally, a survey of new patients on dialysis in one ESRD network showed most were unaware of their modality options: 66% were not presented with the option of PD; 88% were not presented with the option of HHD; and 74% were not presented the option of transplantation.
“The bottom line is if you intervene in that transition, you have a significant chance of making a difference in patients’ education, choice and how they do,” Lockridge said.
In addition to patients new to dialysis, Lockridge recommends TDC units for patients who have experienced failure with PD or HHD.
Emphasis on education
Debbie Cote, MSN, RN, CNN, NE-BC, is overseeing a TDC unit at University of Virginia (UVA) Health System. In the first year of operation, UVA reported improved outcomes for the 17 patients in the program, including a significant decrease in dialysis-related hospitalizations and readmissions. Cote credits these improvements to the educational component of the program, which begins in the first week and incorporates meetings with a dietician, a social worker and a nurse in addition to a nephrologist.
“The first week is helping patients cope with the changes in their lifestyle and getting to know them,” Cote said. “It is an intense time for social work.”
Cote said patients can become overwhelmed by fear and confusion when their kidneys initially fail. Patients have to navigate medical and financial decisions, all while experiencing uremia, which increases feelings of mental confusion. A social worker at a TDC unit can reassure the patient and answer their questions.
The second week focuses on teaching the patient about renal replacement therapies, and the third week builds on and deepens this knowledge. In the last week, the patient and the care team put a plan together for the patient’s chosen modality and their transition out of the TDC unit.
The UVA patients underwent dialysis 4 days a week for a total of 12 to 14 hours per week, using NxStage HHD machines.
While the program did not have the staffing to accommodate a Saturday offering in order to avoid the “killer gap” on weekends, Cote said the use of a slower machine offered four times a week instead of three still allowed patients to benefit from gentler treatment.
“If patients feel the difference on the home machine and see us using them and they want to [choose] home hemo[dialysis], then they have already had some exposure,” Cote explained.
While Lockridge has historically supported HHD over in-center dialysis, he emphasized the importance of ensuring patients know all of their options.
“If we educate the patient, the patient will drive [the care] and the provider will provide,” he said.
Lockridge said the main challenges to implementation are economics and staffing. That is why the manual offers implementation strategies and infrastructure and logistical planning resources, covering everything from medical record and billing integration to suggestions on obtaining buy-in from physicians, nurses and external healthcare partners.
“Hopefully, we are going to see demonstration projects coming out of CMS,” Lockridge said, noting that the cost to CMS and insurance is 10-times greater during the transition period than at other times while a patient is on dialysis. Ultimately, an increase in appropriately run TDC units should lead to reduced readmission rates, reduced hospitalization rates and improved quality incentive program measures.
“We think it’s a win for the provider. We think it’s a win for the patient. We think it’s a win for the nephrologist,” Lockridge said. – by Amanda Alexander
Bowman B, et al. Am Jrnl Kid Diseases. 2018;doi: 10.1053/j.ajkd.2018.01.035
Mehrota R, et al. Kidney Int. 2005;doi:10.1111/j.1523-1755.2005.00453.x
Disclosures: Cote reports no relevant financial disclosures. Lockridge reports since his retirement in 2013, he is a member of the speakers bureau for DaVita Inc., Fresenius Medical Care and NxStage Medical Inc. concerning “Practical Aspects of HHD” and the “TCU Concept.”