Creating a Culture that Promotes Home Dialysis

One of the primary goals of value-based kidney care is increasing optimal starts — when a patient receives a preemptive transplant, starts in-center hemodialysis with a permanent access, or begins home dialysis — to reduce complications, improve outcomes, and reduce the total cost of care. As an alternative to in-center dialysis, home dialysis can offer patients increased flexibility and has been linked to improved outcomes, and in 2019 the White House issued an executive order to incentivize increased home dialysis rates.¹ Yet barriers including the need for increased education and care team training prevent some patients and providers from considering home dialysis as an option.²

 

With six office locations throughout southwest Missouri, Springfield Nephrology Associates has a strong home dialysis program, with up to 35 percent of patients starting dialysis at home — more than twice the national average (13.7 percent) ³. Dr. Ethan Hoerschgen, a nephrologist in the practice and part of the Interwell Health Provider Network, has personally seen how home dialysis improves outcomes and quality of life for his patients.

Q: What is your personal experience treating patients with home dialysis?

EH: I didn’t have a lot of experience with home dialysis before joining Springfield Nephrology Associates. A lot of what I’ve learned comes from my partners here and what they started 12 years ago taking a whole team approach and developing a strong home therapies team. I admit, I felt a little bit of peer pressure to see what home therapy is about.

As I started more of my own patients on home therapies, I quickly realized the benefit as I saw their outcomes and quality of life improve. They seem to be more satisfied and feel more in control as participants in their care. Starting dialysis is a big change, and the less invasive it can be on patients’ daily lives, the better.

I believe my experience reflects a lot of what the clinical data shows: patients’ health outcomes seem to be better, there are fewer hospitalizations, and overall moods are better. Particularly early on, starting dialysis at home has shown a lot of health, quality of life, and emotional benefits, and I think ultimately it’s easier on family as well.  

Q: Springfield Nephrology Associates’ home dialysis rate is well above the national average. How have you been able to achieve such strong results?

EH: When I joined, our home dialysis rate was about 20 percent as a practice. Today, about 50 percent of our patients say home dialysis is their first-choice modality once they are educated on it. That doesn’t mean every patient who chooses home dialysis ends up at home; about 30 to 35 percent of our patients start on home therapies, while the national average is around 15 percent.

I wanted to keep growing our home dialysis program because I saw the patients got amazing care, and that’s because we have an amazing care team. Our patients have physicians, nurses, social workers, and dietitians; it’s almost like a family at our practice. We also have Interwell renal care coordinators (RCCs) embedded in our practice who help coordinate care and ensure patients receive early education about all their treatment options. That whole team approach means a lot to patients.

Optimal starts are the one thing you can modify during the first two years of patient care. With the shift to value-based care and through our partnership with Interwell, the importance of optimal starts is more recognized, and it has become easier to discuss how to get patients access to home therapies.

Q: What are some of the biggest barriers to home dialysis?

EH: Based on my experience, I see very few barriers to patients going home.

One of the biggest concerns I hear is compliance. A lot of times physicians think to themselves, “This patient didn’t take care of their diabetes. They didn’t take care of their high blood pressure. Why would I ever think they would do dialysis when they get home?” What I’ve experienced is the opposite, though. When patients have more control when it comes to something as severe as kidney disease, they become more attuned and start to take better control of their diabetes and blood pressure.

We also have to be careful about making preconceived notions about patients based on factors such as their age. A lot of patients may be one person when they’re in your office, but when they’re at home they’re a completely different person.

I try to be careful of caregiver fatigue. At first home dialysis can be stressful to the caregiver, but I think they also see the benefits of their loved one being healthier and that helps with the care.

Q: What is your approach to educating patients on modalities, including home dialysis? At what stage do you approach early education?

EH: I follow a 30/20/10 philosophy. I first bring up dialysis when a patient’s GFR (glomerular filtration rate) is around 30. Discussions around therapies and preparedness start around 20. As patients get closer to a GFR of 15, then we’re making sure they have at least met with our education team and are getting prepared for their choice of treatment. When a patient’s GFR drops to 10, depending on other factors, that’s when I tell them it’s time to start with their modality of their choice.

Q: How can we incentivize more providers to consider home dialysis as a modality for their patients?

EH: Once physicians experience home dialysis, they realize it is the right choice for a lot of our patients. There is a focus on training new nephrologists on home therapies, and I’m hoping as we see providers coming out of that training that the new generation will bring up the old.

Financial benefits are also helpful. The bundled system created an uptick in home therapies, and I think you’ll see a bump from the government’s kidney care initiative that started a couple of years ago. Interwell has taken a strong interest in getting patients into home therapies. In our practice, we have financial incentives as well, and it would be nice to see more practices reward providers that promote home therapies.

It’s not just important to engage providers; you also need buy in from nurse practitioners, medical assistants, and dialysis unit staff. Our hemodialysis nurses who don’t even take care of patients on home therapies look for patients who can benefit from going home. In our practice, everybody can recommend home dialysis to patients.

Interwell prioritizes provider and patient education to improve home dialysis rates and consistently achieves start rates above the national average for our patient population. Read how Interwell is helping providers overcome obstacles to boost home dialysis. 

 

References

1. Healio: Trump executive order pushes for 80% of ESKD patients to have transplant or be on home dialysis by 2025. https://www.healio.com/news/nephrology/20190710/trump-executive-order-pushes-for-80-of-eskd-patients-to-have-transplant-or-be-on-home-dialysis-by-20
2. American Journal of Kidney Disease: Identifying Major Barriers to Home Dialysis (The IM-HOME Study): Findings From a National Survey of Patients, Care Partners, and Providers. https://www.ajkd.org/article/S0272-6386(24)00790-X/fulltext
3. NIH: Kidney Disease Statistics for the United States. https://www.niddk.nih.gov/health-information/health-statistics/kidney-disease