The Beginnings
The decision to expand into home hemodialysis at the Dialysis Center of Lincoln began about two years before we actually initiated the program in August 2003. Our in-center hemodialysis program had been rapidly expanding. We were outgrowing the two units previously built in Lincoln, Neb. We also had two small satellite units, one 50 miles away in Beatrice, Neb., and one 90 miles away in Columbus, Neb. Our peritoneal dialysis program, after reaching a maximum of about 90 patients in the late 1990s, had been decreasing to around 30 to 40 patients. We were being asked to consider building new facilities in smaller communities outside of Lincoln. Patients, who were traveling farther to access dialysis, were forming committees in small towns to raise money to build dialysis units. We had five nephrologists in our practice and had increasing pressure to travel greater distances to see patients. Our satellite clinics were not always profitable and the efforts to maintain financial viability was being called into question. It was in this setting that expansion to home hemodialysis seemed to be the next logical expansion.
We had always had a very strong home dialysis program with peritoneal dialysis, but as patients came off peritoneal dialysis for various well-known reasons, patients who were used to independent lifestyles and lived some distance away began to demand better access for therapy. We examined traditional home hemodialysis, but this was going to be expensive to maintain and required prolonged training times. I had some experience in the past with home hemodialysis patients in my fellowship and early career, but none recently. I became aware of a home dialysis machine from Aksys® PHD system that provided home hemodialysis in a user-friendly format and could be taught in two to three weeks of daily training. I attended several national meetings and talked to marketing representatives of the Aksys® Company. No dialysis units in the area were offering this technique. The CEO for our independent not-for-profit unit and I traveled to the headquarters in Chicago and made an appeal as to why we should have a home hemodialysis training unit for Aksys® PHD system in the center of the nation, rather than only in large cities, where they were currently focusing their marketing activity.
In our rural practice area, it would be more cost effective to offer home hemodialysis to individual patients in rural areas, rather than build small hemodialysis units all over the state of Nebraska. At the time, there were only two nephrologists in the entire state west of Lincoln. We had peritoneal dialysis patients all over the state, but dialysis units were usually at some distance for access to in-center treatments. By expanding into home hemodialysis, we could expand our reach across the state and not have to build new units at substantial cost nor would this require travel expense on our part. We were successful, and Aksys® agreed to support our program.
The Planning
The next decisions to be made were: (1) Where would we house the program? (2) What would be our criteria for acceptance of patients into our program? (3) What expenditures were we willing to make to get the program started? Our peritoneal dialysis nursing staff immediately volunteered for the new program. They were already heavily involved in patient teaching and home dialysis, but hemodialysis would be a very different technique for them. They quickly learned the techniques with the help of Aksys® staff. We started the program with three full-time peritoneal staff nurses plus part-time help from dietitian, social work, and inventory control. Inventory control was critical to our peritoneal dialysis program and is important in home hemodialysis.
Our criteria for acceptance into the program have changed over the years, but initially our criteria started out with: (1) a primary AV fistula access, (2) the patient or partner demonstrated the ability to cannulate the fistula using button-hole technique, (3) a helper available to assist the patient during the training process and would be available at home during the procedure to assist with emergencies, (4) adequate ability to learn the technique, and (5) a home environment that could be altered to meet the necessary plumbing requirements. We also learned that access to appropriate potable water in the home is important. In Nebraska, water for local consumption has a high degree of variability and variable purity. Often, patients’ homes are supplied with well water which is not regularly tested to meet Safe Water Drinking Act standards. We decided to place no restrictions on co-morbidities, age, or distance from the center (we had a patient who lived in California for a time). We agreed to try and train anyone who was interested and motivated to learn the therapy. We would learn along with the patients.
To get the program started, we allotted staff time to be trained initially, and designated a head nurse for peritoneal dialysis and a head nurse for home hemodialysis. All of our home nurses were cross-trained for both peritoneal dialysis and home hemodialysis. One nephrologist was the medical director, but all of the nephrologists in our group referred and trained patients on the technique. We all had to learn together. We then sent those nurses into our in-center population and taught the in-center nurses the technique of button-hole cannulation of AV fistulas and started recruiting patients from our in-center hemodialysis population. We made them available to talk to any patient who expressed interest in the technique. We sent notices to all of our patients advising them of the program. We offered them the opportunity to dialyze with one of our machines to see how it worked.
