How we did it: Dialysis Center of Lincoln; Lincoln, Nebraska

There were three reasons that Dr. Leslie Spry, Medical Director of the Dialysis Center of Lincoln, decided to expand the center's home hemodialysis program:

  • Excellent clinical outcomes among home patients
  • Long travel distances facing rural Nebraska dialysis patients
  • Availability of new, easy-to-use home hemodialysis equipment

All 3 came together in August 2003 —and Dialysis Center of Lincoln became the first dialysis center in the Midwest to offer short daily home hemodialysis. Here's what they did.

Established home program

There has always been a home dialysis program at Lincoln since the nonprofit center opened more than 15 years ago. "We've always offered our patients PD," reported Home Dialysis Nurse Michelle Carver. In addition, conventional home hemodialysis has been provided for "a few patients" for several years.

The home dialysis team at Lincoln began looking into adding short daily home hemodialysis treatment options when they learned that the Aksys® Personal HemoDialysis System (PHD) had earned FDA approval. "I kept calling Aksys and bugging them about the machine," remembered Carver. Thanks to her persistence, Lincoln was the first center to make the PHD available to patients in the Midwest.

The fact that Lincoln had an established home program in place for both PD and hemo meant that they did not have to apply for a new certification in order to offer short daily treatment to home patients. However, there was still plenty of work to do.

"It took us about 2 months to get organized," recalled Carver. "We developed our own training manuals and training program checklist, and we needed to get policies and procedures written and approved." It helped that they could adapt manuals provided by Aksys, as well as their own conventional home hemo documents.

Organizing for growth

The decision to add a new home dialysis option for patients prompted Lincoln to re-evaluate staffing allocations, too. Carver, for example, had been serving as Education Coordinator, staffing the in-center hemo unit, and managing a handful of home hemo patients. With the home program poised to grow, she had to make a choice—either stick with education or become the Home Dialysis Coordinator. She chose the home program.

Other staffing changes were made, too. Dr. Timothy Goverts was appointed Medical Director of the Home Program, and physicians at all 4 Lincoln satellites agreed to rotate home hemo call. In addition, home nursing staff members were cross-trained to cover both PD and home hemo. "Jean Garrison, RN was the PD nurse, and she and I cross-trained each other in the beginning," Carver explained. "I learned about PD from her and she learned about home hemo from me." Since then, Lincoln has added 2 more home nurses—Marlene Cassagnette, RN and Kanda Wurm, RN—to provide enough nursing coverage for home training and call.

Recruiting patients

"Our very first short daily home hemo patient came to us," noted Carver. "Our website mentioned the fact that we were willing to train for short daily home hemo. She saw it and called us. Then, she transferred to our unit to be able to do it." That first patient went home in August, 2003.

Since then, the Lincoln home dialysis program has grown—for all modalities. "PD has grown from about 20 to almost 40," Carver reported. And, there are currently 24 home hemo patients, with a waiting list of 7 more." (The in-center program serves about 280 patients.) In addition, short daily patients now have the option of using either the Aksys PHD or the NxStage System One home hemodialysis machine.

Carver attributes the growth of the home program to active education about options. "We feature home treatment as an option in our predialysis classes," explained Carver, "and we do education for current in-center patients, too." Because the physicians at Lincoln are supportive of home dialysis, they also talk to patients about doing dialysis at home.

It helps that the "selection criteria for home patients are pretty open," Carver noted. "They have to have a partner who agrees to be there during dialysis and commit to monthly clinic visits," she said. For current in-center patients, the home staff looks at compliance, too. "If there were any compliance problems, we evaluate the reasons," added Carver, "sometimes it's the in-center schedule that is the problem—not the patient."

Start-up and training

Although the staff at Lincoln makes sure patients know about home options, they don't push the programs. "We leave a lot to patients, " explained Carver. "Letting them take the first step helps weed out the ones who are not really committed to taking care of themselves."

Once a patient does call, the home staff will talk with the nephrologist and set up a meeting with the home nurses and social worker. A home visit is scheduled and equipment preferences are discussed. Patients who are interested in home dialysis must commit to training—5 days a week for 2-3 weeks. In-center patients must also start self-cannulating before they begin home hemo training. Once all the plans are in place, the home staff arranges a training start date and makes sure that the home is set up to handle hemodialysis equipment. "I never thought I'd learn so much about plumbing!" joked Carver. A final home visit on a patient's first day home completes the start-up and training program.

Patients return for monthly clinic visits, but have access to home dialysis nurses and doctors via phone 24 hours a day. "We thought we'd get a lot of phone calls from our home hemo patients," Carver recalls, "but actually they are the patients who call the least." She thinks it's because they are prepared to solve problems.

Rewarding results

Carver has not ever regretted her decision to focus on home dialysis nursing. "I love it!" she said. "It is so rewarding to see the patients. They look like different people after just one month. And, they're so knowledgeable."

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