Dialysis in Nursing Homes and Residential Care

Facilities

Triumphs and Challenges 1

Speakers ´ Susan Markovich MBA, RN, CNN

VP Clinical Operations Affiliated Dialysis Centers Glen Ellyn, IL ´ Nola McMullen, RN Chief Operations Officer

Reliant Renal Care, Inc. Media, PA

´ Glenda Payne, MS, RN, CNN Director of Clinical Services Nephrology Clinical Solutions

Lisle, IL

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Disclosures

´ Ms. Markovich and Ms. McMullen work for companies that provide dialysis in nursing homes

´ Ms. Payne works for a consulting company that has provided guidance to companies that wish to provide dialysis in nursing homes

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Objectives:

•  Identify current regulatory requirements applicable to providing dialysis in long term care (LTC) facilities

•  Describe challenges of providing dialysis in LTC

facilities •  Detail effective options to meet the challenges of

providing dialysis in LTC facilities •  Discuss outcomes of patients receiving dialysis in LTC

facilities

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To Be Clear:

´ This session is about dialysis IN nursing homes ´ Not about dialyzing nursing home patients

in an outpatient center. ´ Acronyms used interchangeably here:

´ LTC: Long term care ´ NH: Nursing home ´ SNF: Skilled nursing facility

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Applicable Regulations

´ Reimbursement regulations

´ The current ESRD quality & safety regulations are silent on dialysis in nursing homes

´ However, there is some guidance from CMS…

´ Vary greatly from state to state

´ From no regulations

´ To very specific

Federal

State

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Federal Guidance for Dialysis IN Nursing Homes

Official: Survey & Certification Letters, 2004

´ Based on “old” ESRD regulations

´ Currently being updated

´ Potential release date of update: Unknown

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Survey & Certification Guidance, 2004

´ Separate guidance for: ´ ESRD surveyors ´ LTC surveyors

´ Major points: ´ ESRD surveyor expected to visit one or more LTC ´ Contract required between LTC /ESRD

´ Collaboration is expected ´ Infection control practices ´ Machine storage ´ Water treatment ´ Emergency equipment & response

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Survey & Certification Guidance, 2004

Staffing requirements ´ A qualified ESRD nurse is responsible for training

patients/caregivers & LTC staff ´ An appropriately trained caregiver provides

monitoring of the patient during dialysis ´ A licensed health professional “experienced in

rendering ESRD care” is on duty to oversee dialysis ´ Perform assessments, observe patients pre/post

tx, respond to ER situations, administer injectable meds

´ Full IDT provides care

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Survey & Certification Guidance, 2004 ´ Patient Care Plans:

´ Individualized

´ ESRD IDT team responsible to develop plan and communicate with LTC to address patient needs

´ Coordinated with LTC care plan

´ Patient Rights & Responsibilities:

´ Patient/family informed of options

´ Aware of grievance/complaint procedures

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Survey & Certification Guidance, 2004

QAPI

´ Patient outcomes are monitored

´ Identified problems are addressed

´ Incidents and accidents involving dialysis care in the LTC are reported to both the LTC and the ESRD

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What Might New Guidance Include?

Draft Letter “released” in 2012

´ A qualified RN, LPN, or Certified PCT must be “present in the room” during dialysis

´ No more than 2 patients in a room where dialysis is done

´ At least quarterly reassessment/plan of care

´ MSW/RD communicate monthly with LTC staff/patient

´ Care coordinator for each LTC dialysis patient

´ Weekly audits of treatment records

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What Might New Guidance Include?

Draft Letter “released” in 2012:

´ Monthly face-to-face contact medical staff/patient

´ Monthly home visits

´ Quarterly competency checks for caregiver

´ A qualified RN on site & available to respond throughout the treatment

´ QAPI: compare aggregate outcomes of LTC patients with aggregate outcomes of in-center patients

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What About State Regulations?

Important to consider all potentially applicable regulations:

´ Nurse Practice Acts (NPA) (all 50 states have these)

´ ESRD licensing regulations (~ 30 states have these)

´ Home health (HH) licensing regulations (multiple states have these)

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A Couple of Examples

´ NPA: Only RN can assess ´ ESRD licensing

´ HH licensing

´ Required to provide care in home

´ Specific rules for HH with “dialysis designation”

´ Only licensed nurses can provide dialysis

´ NPA: specific language addresses home HD

´ Allows non-professionals to give injectable meds as part of home dialysis

´ ESRD licensing: No

´ HH licensing: No

Texas Florida

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Why Do Dialysis in Skilled Nursing Facilities?

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How Is Hemodialysis Done in Nursing Homes?

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What Are the Challenges in Providing Dialysis in LTC?

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What About Patient Outcomes?

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Conclusion

´ Dialysis in SNF is a much needed service

´  Improved quality of life and outcomes

´ Daily therapy the best option

´ Challenging environment to operate in

´ Frequent survey activity

S

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Questions?

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References ´  Canaud,B., et al. (2011). Clinical practices and outcomes in elderly

hemodialysis patients: results from the dialysis outcomes and practice patterns study (DOPPS). Clin J Am Soc Nephrol 6: 1651–1662, 2011. doi: 10.2215/CJN.03530410

´  CMS Survey & Certification Letter (2004) retrieved from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/SCLetter04-24.pdf

´  United States Renal Data System. 2015 USRDS annual data report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2015.

´  Weinhandl, E., Liu, J., Gilbertson, D., Arneson, T,. & Collins, A. (2012) Survival in daily home hemodialysis and matched thrice-weekly in-center hemodialysis patients. JASN. Feb 23, 2012. doi: 10.1681 ASN.2011080761

´  Yang, et al. (2014). Survival Comparison of daily home dialysis vs. conventional in the nursing home setting. NNI. 2-2014

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