How we did it: Mt. Airy Self-Care Dialysis; Philadelphia, PA

Reproduced with permission from Nephrology News & Issues, September 2007

A bridge to home dialysis

For patients who are afraid to attempt home dialysis, in-center self care may create a bridge and an opportunity to transition to home after a period of confidence-building adjustment. For those who don't have a helper or who live in an unmodifiable rental, in-center self care has the potential to offer better outcomes than standard, in-center treatment.

Self-care improves outcomes and outlook

When Dr. Edward Jones, Medical Director of the Mt. Airy Self-Care Dialysis facility in Philadelphia, compares the 50 in-center self-care patients in his clinic with the patients who are dialyzed in a traditional staff-assisted facility, he sees major differences. "The self-care patients definitely have better outcomes and better attitudes about taking care of themselves," he observed.

Less morbidity and mortality

Based on data he has collected, Jones concludes that his in-center self-care patients experience significantly less morbidity and mortality. Specifically, compared with national averages for all hemodialysis patients, Jones' in-center patients had:

  • 66% fewer days in the hospital (4/1000 dialysis days vs. 12/1000)
  • Half the mortality (9-10% vs. 22%)

Jones reports that serum albumin and serum phosphorus levels are better in the self-care group than in the staff-dialyzed group, too.

"There is some selection bias in the population," Jones admitted, "because the self-care patients tend to be younger (on average 10 years younger)." He also conceded that the people who choose self-care might be more motivated to take care of themselves. "It is difficult to do a controlled study, so I haven't published my data," he added, "but it's clear to me that in-center self-care is an excellent modality."

More patient empowerment

"Self-care gives patients the responsibility for their own health," commented Jones. He finds that these patients understand their disease process, dialysis, and what they need to do in terms of watching diet and fluids. "If they do end up in the hospital, 90% can rattle off their meds and doses," he added.

Self-care patients at Mt. Airy Dialysis set up their own machines (Fresenius 2008K); rinse their dialyzers; and administer their own EPO, iron, and vitamin D analogs. Many place their own needles. They track and log their blood pressure during treatments, and clean the chair and strip the machine when they're through. "They do it all," said Jones, "and our staff has been trained to encourage them."

Promoting self-care

Classes for predialysis patients always include a presentation of all available modalities, including in-center self-care. "If a patient seems interested, we push self-care a little and encourage them to give it a try," noted Jones. "Anybody can do it if they want to, and most who start, stay with it. Very few have quit," he added, "and the self-care unit is constantly full."

Every staff member at Mt. Airy is committed to helping patients take care of themselves. Patients who choose self-care begin learning how to operate their machines on Day 1. Even patients in the regular unit (sometimes referred to as 'modified self-care' are encouraged to do some things, for example, tearing their own tapes or taking their own blood pressures.

Keys to success

With 50 self-care patients and 20 years of experience, Mt. Airy Self-Care Dialysis might be one of the largest—and oldest—in-center self-care units in the country. What's behind their success? "Your staff absolutely has to be on board with self-care," advised Dr. Jones. He credits his staff, including training nurse LaRhonda James, RN, and technician Van Price, for setting the right tone. Physical separation from patients who are being dialyzed in a staff-assisted unit is also key. "You cannot mix the two groups of patients in the same room," he noted, "or some self-care patients will begin to ask 'Why do I have to do this myself?'"

Win-win situation

In-center self-care programs can be beneficial for the dialysis clinic as well as the patients. Jones noted that the staffing ratio in a self-care program is reduced, with two techs and one nurse for every 10 self-care patients.

"There are some financial benefits, too," added Jones. For example, patients who are being trained for self-care can receive Medicare benefits from Day 1; they do not have to wait for 90 days. In addition, the dialysis clinic is reimbursed for training costs, and physicians, too, are paid from the first day of dialysis.

"Lately, there is more interest in in-center self-care than there has been for years," said Jones. "The benefits for patients and providers certainly warrant a good look."

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