Rubin Dialysis Takes a Chance on Home Dialysis

Ten years ago, the Rubin Dialysis Center in upstate New York started an Internet-monitored nocturnal home dialysis program with the knowledge it was going to lose money. “I told my board we were going to lose money for two-and-a-half to three years, and we were pretty close,” Wayne Evancoe, CEO and administrator of Rubin said. “For two-and-a-half to three years, we did lose money, but broke even at about 20 patients.”

Today, the Rubin Dialysis Centers have about 40 patients on NxStage’s portable home hemodialysis machine. In all, Rubin’s home program boasts 85 patients using the NxStage machine, Fresenius’s dialysis machine, or peritoneal dialysis—that’s about 24 percent of the dialysis system’s 350 patients.

The Hortense & Louis Rubin Dialysis Center is a nonprofit organization with three upstate New York outpatient dialysis located in Saratoga, Troy and Clifton Park.

“When NxStage came out in 2005, we jumped on that technology,” Evancoe said. “NxStage has been a real boon to us and to patients in that it’s modular, more portable, easy to learn and more economic. We found that a larger slice of the patient population can adapt and learn the NxStage.”

Part of the inspiration for starting the nocturnal program at Rubin was though research done in Canada by Andreas Pierratos, MD, who is with the University of Toronto, and has worked on the early development of nocturnal home programs. “What we’d seen is that they were monitoring people 200-300 miles away,” Evancoe said. “It’s not really dependent on bricks or mortar. We don’t want to only serve the immediate population of dialysis patients. We want to be able to go out with the best technology possible, the best training possible, the best support possible, which is all essential to keep patients in their homes. There’s less infection, there’s less time wasted with transportation, and their clinical results are astounding sometimes. There’s a lot of reasons to do it; we, as a not-for-profit, do it because it’s the right thing to do and people have a much better quality of life.”

Looking for Patients

Not all patients are candidates for home dialysis, and the ones that are have to be scoped out by the clinic. The optimal patient mix depends on the institution, Evancoe said. “We really search our population as they come through the door,” he added. “We look to see if they are coming from a hospital or if they’ve been dialyzing with us for years. Do they look like an appropriate candidate that has enough tactile vision, hearing and other abilities to learn home treatment? We’ve taught retired housewives, factory workers, graduate students, to retired priests who felt so good on nocturnal, they came out of retirement and started performing Mass again. We’ve had some wonderful success stories.”

The Open House Approach

Another way to get dialysis patients interested in the possibility of home dialysis is to get them to come in to the centers and ask questions. Therefore, once or twice a month, the center will hold an open house in which any patient from any practice in the area can come in and ask anything they want about peritoneal dialysis, nocturnal dialysis or short daily dialysis.

Evancoe said they will have machines and brochures available for the patients, but it is often a vocal patient or spouse already using the home modality who will be the greatest resource to enquiring dialysis patients. “It is really the personal testimony to other patients,” Evancoe said. “They can ask their questions, not to the guy in the suit, the nurse, or whoever it might be from the institution, but another patient or a patient’s spouse. It’s very accessible.”

After the open house, Evancoe said about 20 percent of the patients follow up to look into the home therapies a little more seriously. At that point, the Rubin centers will bring these patients in to talk to them about the clinical aspects of the treatment. In addition, they will also have a social worker speak with the patients to ensure they are well versed and understand what they are getting into.

Once the patient is on board with the home program, Evancoe said the clinic is looking at about two to three weeks in order to get patients comfortable enough to start using the NxStage equipment. “We keep up with the latest literature and best practices as far as buttonholing with fistulas,” Evancoe said. “[Patients] can use blunt needles at home, so there isn’t a need for sharps. Blunt needles are a bit safer, and as long as they’re doing their own cannulation, it becomes routine, and they don’t have five different people sticking the same site. There is less chance for infection and more success for the access. We also train people with catheters and grafts, but we do prefer the fistula.”

Monitoring Home Patients

Although a patient might be at home dialyzing miles away from the center, he or she isn’t far from the minds of those working at the clinic. The Rubin centers specifically hire technicians for the purpose of monitoring home dialysis patients during treatment. As soon as the patient turns on the machine, he or she is automatically connected to Rubin’s Internet access. These observers will monitor the patient’s vital data stream that is coming directly from their house.

The technicians are essentially looking at a live feed of the home patient’s data feed. The monitoring system also includes an alarm system. If something does go wrong, the staff is trained to call the patient within 120 seconds. That means the patients are required to have a phone next to their home treatment system. In addition, there is always a nurse on call in case there is a clinical issue that needs to be addressed, according to Evancoe, and beyond that, the nephrologist is always available beyond the nurse if he or she is needed.

NxStage Advantages

One advantage patients have in using the NxStage portable dialysis machine, Evancoe said, is water usage. “NxStage has a business model,” Evancoe said. “It’s very expensive to ship water all around the country.”

NxStage’s PureFlow system creates 60 liters of ultra pure water and can be used for up to three treatments at 20 liters per night, according to Evancoe. Therefore, it doesn’t use huge amounts of water and electricity and helps patients control the utility costs in their homes.

In addition, if a patient has a problem with the NxStage machine, Evancoe added, they can have a replacement the next day. “It’s a nice plug ‘n play situation,” he added. “You don’t have to go out there with a technician and work in the field. That incurs a lot of cost for me, time for us and lost time for the patient.”

The Family Effect

Patients generally feel more empowered on home dialysis, Evancoe said, but that can vary from patient to patient. But it’s also a family adjustment for the patients. “Some people feel that when the machine goes home, the disease becomes the family’s, instead of ‘Gee, Mom and Dad are going away for five hours, three days a week,’” Evancoe said.

The Rubin centers prefer to train patients for home who have a significant other for support, even if they are on nocturnal monitoring. The centers will even have Sunday breakfast from time to time with a patient’s partners to continue their education. The trick is to make dialysis as routine as possible in the home. That has become easier as new technology has made it faster and more seamless to start each session. Evancoe said the old nocturnal systems could take up to an hour to set up and an hour to take down, in addition to dialyzing six to eight hours in the night. “With NxStage, you’re probably looking at 18 to 20 minutes [set-up time],” Evancoe said. “It doesn’t have the burnout factor that can occur, and it’s less burden for a significant other or a spouse.”

Medicare Limitations

Currently, Medicare, across the board, only reimburses dialysis treatments three times a week. This can place a considerable burden on a clinic that is trying to champion a home program that has patients dialyzing four or more times over a seven-day period. “We’ve found ways to work with that,” Evancoe said. “We make a margin. As the technology gets better, there are less interruptions and more consistent treatments—and the ability to bill for those treatment—it gets a little more economical.”

Evancoe said his organization is pushing for and advocating for more frequent dialysis and would like to see four treatments a week be paid for. “That would cover my cost and give me a margin, so I can reinvest in staff,” Evancoe said. “RN wages are going up inordinately. They deserve it, but as a not-for-profit going up against hospitals, nursing homes and educational institutions, it’s tough to hire and keep good staff.”

Despite the importance of making sure the program is fiscally responsible for the clinic, it’s ultimately the quality of care that drives Rubin’s desire to continue to the home program.” We’re not paying shareholders,” Evancoe said. “As a not-for-profit, we reinvest in patient care and staff, and replace capital equipment and building needs when necessary. In our case, we see the clinical benefits; it excites the staff. We’re really looking at going after populations, making sure referring doctors at multiple practices refer to us and making sure they understand the choices.” RBT