Home Dialysis 101

I once heard a prominent nephrologist (that is, a kidney specialist), explain that our kidneys do for our blood the same two things that our washers and dryers do for our laundry. First, they clean our blood, removing toxins that build up over time because of the foods we consume and the natural breakdown of muscle tissue, much like washing machines remove dirt from clothing. Then, they “dry out” our blood, removing excess fluid from our bloodstream and sending it to our bladders to be passed as urine and—well, you get the idea.

Over time, chronic conditions such as diabetes and hypertension, along with hereditary traits, can slowly cause our kidneys to fail, a diagnosis known as chronic kidney disease (CKD). When an individual’s remaining kidney function degrades to the point where it no longer supports the aforementioned tasks, the patient has reached end stage renal disease (ESRD). At this point, renal replacement therapy, which is more commonly known as dialysis, is required to sustain life.
How common are kidney failure and dialysis?

• One in seven Americans have CKD
• Almost 555,000 Americans receive dialysis to sustain life
• The United States has more than 7,500 outpatient dialysis centers

CKD is largely asymptomatic, so people don’t often realize that their kidneys have failed until it’s too late, and their transition onto dialysis begins in the local emergency department. At that time, labs are ordered and the on-call nephrologist is consulted because without an order for dialysis, the patient may not be long for this world. As the patient approaches discharge seven to 10 days later, the case manager has work to do—they must find an outpatient dialysis center ready to admit this patient; 96% of these patients will report to a center for chronic dialysis three times per week for the rest of their lives, as only 4% receive kidney transplants.

3 Treatment Options

In all of this turmoil, a silver lining emerges. There are three different modalities to receive dialysis, and two of them occur at home; for the most part, patients who are educated on these choices can take their pick.

In-center hemodialysis (ICHD) is the most common modality, and has patients report to a dialysis clinic in the community and receive treatments that are three to four hours long every Monday, Wednesday and Friday or every Tuesday, Thursday and Saturday. During those visits, nurses and technicians connect patients to hemodialysis machines that circulate a few hundred milliliters of blood every minute through an artificial kidney—a dialyzer—and return it to the body. This is how 83% of Americans experience dialysis and is the only type that requires a patient to report to a center roughly 12 to 13 times per month.

Next is peritoneal dialysis (PD), which 14% of U.S. dialysis patients receive, exchanging fluid in their abdomen.
The peritoneal membrane acts as the dialyzer, and is commonly performed six out of seven nights per week, including while sleeping.

Last is home hemodialysis (HHD) and, while it is clinically similar to ICHD, patients are able to choose when during the day or night to dialyze, improving quality of life and other factors. Unfortunately, only 3% of dialysis patients receive HHD. While ICHD patients report to their center 12-13 times per month, home dialysis patients report back to the center that trained them to do their treatments at home just once or twice per month for lab reviews and nephrologist rounds.

Better Outcomes at Home

In addition to not reporting to a dialysis center nearly as often, what if I also told you that home dialysis patients experience better clinical outcomes, report higher quality of life and consume lower total costs of care? It probably feels like a “no-brainer” that if you were diagnosed with kidney failure tomorrow and had to choose a modality, you would dialyze at home on peritoneal dialysis or home hemodialysis. As it so happens, nine out of 10 nephrologists agree—and would make the same choice.

The reality is that the vast majority of dialysis centers in the U.S. are purpose-built for ICHD, meaning that’s where hospitals are essentially required to send patients, even though the social workers and registered nurses who staff hospital case management departments across the country understand that home dialysis may be better.

While there are several systemic reasons for the stark imbalance between how healthcare professionals would choose home dialysis for themselves and how few dialysis patients are treated at home, I’ll instead focus on the opportunity ahead of us.
Home health and durable medical equipment (DME) companies are experts at addressing patient care needs in patients’ homes, from the occasional delivery of consumable goods to administering medications and managing complex mobility or invasive ventilation. They employ clinical teams, including medical assistants, respiratory therapists, registered nurses and more, along with logistics teams making deliveries and performing repairs on power chairs, beds and oxygen concentrators.
All of these capabilities, when overlaid upon care management workflows from upstream referral source engagement through revenue cycle management and quality reporting programs, make them excellent home dialysis providers.

Because initially training and subsequently supporting patients to dialyze at home requires far less infrastructure than ICHD (think a few hundred square feet, not 5,000) home health and DME companies can build training suites not much larger than those required for CPAP mask-fitting appointments, with residential electrical and plumbing access, within their existing retail footprints. Much of the back-of-house infrastructure, such as employee break rooms and patient restrooms, already exists in retail storefronts for co-use between existing goods and services and dialysis training. Add this physical infrastructure to a DME provider’s existing expertise in upstream referral source engagement, compliance, billing and quality program management, and you have a provider entity that is very capable of adding dialysis care for patients.

Seven out of 10 dialysis patients have one or more comorbid conditions, meaning that home health and DME companies are already caring for dialysis patients whose fragmented care means that some needs are met at home, while others happen three times per week via ICHD.

Take a closer look at diversifying your company and care management team into home dialysis care—I think you’ll find an important mission.