How we did it: Rubin Dialysis Center, Inc.; Clifton Park, Saratoga, & Troy, NY

An interview with Clinical Services Coordinator, Shari Meola, RN, CNN

The Hortense and Louis Rubin Dialysis Center, Inc., has offered a home-treatment option to their patients—in the form of peritoneal dialysis—since 1986. They began offering home hemodialysis options more recently, but their program has grown quickly. Today, almost 30% of Rubin dialysis patients do some form of home treatment: 11% PD, 10% short daily hemo, and 8% nocturnal home hemodialysis. Those numbers are proof positive that Rubin is doing something right!

Getting patients home

Meola and her staff make a concerted, well-organized effort to ensure that every patient knows about all the dialysis options that are available.

Predialysis orientation: "At Rubin, we offer all the modalities to all our patients," said Meola. "Predialysis orientation always includes a discussion of home treatment." A brief description of all the home modalities and the benefits of each is featured on the Rubin website.

Monthly open house: "Once a month the home dialysis program holds an open house to introduce patients and families to all the services we have available," Meola said. "We think this is so important that we actually won't let a patient start training for a home treatment modality unless they've attended an open house." Patients who express an interest in home treatment are asked to call Meola and her staff. "We don't try to recruit them," she explained. "If they want to learn more about home dialysis, they must make the call. We are here to help."

The staff at Rubin also makes sure patients know that choosing a modality is the patient's job.

Freedom to choose: "At Rubin, we tell our patients that the 'right' modality is the one that suits their life, the one they choose," Meola said. "We don't press them to make a choice because we like it. I actually encourage the nurses not to offer an opinion, even if asked," she emphasized. "I tell patients that it doesn't matter what I think, it's their life."

Freedom to change: Meola tries to take the pressure off decision-making by letting patients know that nothing is carved in stone. "We stress that they're never locked in," she said. "If they feel they've made a mistake, they can make a different choice."

Nocturnal home hemodialysis

The Rubin Dialysis Centers first offered nocturnal home hemodialysis in 1998. "I had been reading about Dr. Andreas Pierratos and his experiences with nocturnal dialysis," recalled Meola. "I thought it sounded interesting, and Dr. Hoy agreed." The members of the Rubin team went to Toronto to see the program for themselves and were "sold" on the idea when they met Dr. Pierratos' nocturnal patients. "They were doing so well," Meola remembered, "that we knew we wanted to offer nocturnal dialysis to our patients."

At the time of this interview (May 2007) Rubin had 21 nocturnal home patients and was participating in a National Institutes of Health (NIH) study "to determine if there are benefits of Nocturnal Home Hemodialysis (NHHD) compared to home hemodialysis, three days a week."

Short daily home hemodialysis

In November 2005, the Rubin Dialysis Center expanded its home hemodialysis program to include short daily home dialysis using the NxStage System One.

As of May 2007, there were 26 NxStage patients in the Rubin home program, and Rubin was one of several dialysis centers around the country participating in the NxStage Freedom study to evaluate outcomes and quality of life in patients who do short daily home hemodialysis. "We have a support group for our patients using this form of treatment," reported Meola, "and they tell me they prefer being home. Not one would ever go back to in-center dialysis."

Keys to success

According to Meola, several factors have contributed to the success of Rubin's home program.

Strong Staff Team: "We have a very cohesive, strong team of nurses and techs in our program," Meola said. "They love what they do and there is good, open communication." She stressed the importance of staff flexibility. "It's usually 3 in the morning when patients call with a problem," she admitted, "and your staff has to be willing to handle those calls."

Physician Commitment: "Dr. Hoy, Dr. Daoui, and other progressive nephrologists in our system are strong believers in home dialysis," noted Meola. "They believe that home dialysis is best for patients and they wholeheartedly support the home program."

Help with Transitions: "Over the years we've learned that going home is easier if we assist patients with the transition," said Meola. The tech and nursing staff visit every home to assess suitability, and a home nurse is always present for the first at-home dialysis session. In addition, Meola noted that most of their home patients initially dialyze in-center and then go home. "If they're on the dialysis floor for awhile, we can see how they adjust to dialysis and they can see what it feels like," Meola commented. "We can also focus on self-cannulation training in a more-closely supervised situation."

Continuous Training: Home dialysis training is available at all three Rubin Dialysis Center locations, and there are always sessions in progress. "We're always training," noted Meola, "so it is more accessible to patients who are interested."

Worth the effort

Meola believes that training patients for home dialysis is worth the effort. "Once patients get home they usually do very well, and that is satisfying to see," she said. In addition, staffing efficiency can often be improved. "Our clinical-staff-to-patient ratio for in-center hemodialysis is 1 to 4," she reported, "while the ratio for home dialysis might be 1 to 15." Still, the best reason to offer home dialysis options—and the reason The Rubin Dialysis Center is so committed to it—is the positive impact it can have on patients' lives. "Our motto is 'Dialysis on Your Schedule—NOT Ours!' and that is one way our patients gain control of their lives and self-care again."

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