Home hemodialysis (HHD): Establishment of a program

INTRODUCTION — Home hemodialysis (HHD) has become more popular due to increased patient interest and financial incentives associated with this therapy. Consequently, the opportunity to care for HHD patients is growing. However, most nephrology fellowship graduates consider their training in HHD inadequate [1]. While some programs do incorporate patient care aspects of HHD in their training programs, the training on how to set up a program is often lacking. This review will outline essential elements of an HHD program.

Details regarding the advantages of HHD and the care of an HHD patient are presented elsewhere:

●(See "Outcomes associated with nocturnal hemodialysis".)

●(See "Technical aspects of nocturnal hemodialysis".)

●(See "Short daily hemodialysis".)

●(See "Short daily home hemodialysis: The low dialysate volume approach".)

INFRASTRUCTURE — The infrastructure of an HHD program includes a dialysis clinic and a part of the patient's residence. Thus, all aspects of a dialysis program, such as physical space, safety, dialysis equipment and supplies, infection control, staff competence (dialysis staff, the patient and/or partner), and medication administration must be addressed for both the HHD clinic and the patient's residence.

Physical space — HHD shares more logistical similarities with peritoneal dialysis (PD) than with in-center hemodialysis (ICHD). As an example, methods of training, monthly clinic visits, and care coordination between the dialysis clinic and the patient's home are similar for HHD and PD. Thus, it may be beneficial to integrate an institution's HHD and PD programs within the same physical space for efficient utilization of shared resources. A PD and HHD program together typically constitute a home dialysis program.

A home dialysis program can be located in a new stand-alone facility, a new dialysis facility with HHD, PD, and ICHD infrastructure, or in the same facility as an ICHD unit by renovation of an existing unused space (table 1). Some advantages of colocalizing an ICHD program and home dialysis program together within the same facility include the ability to share conference rooms, staff break rooms, storage space, and support staff. This colocalization also helps create an opportunity for the home dialysis staff to interact more with ICHD patients and staff, which enables more frequent and consistent modality education bilaterally.

However, renovating an existing space within an ICHD facility may limit the provision of appropriate aesthetics and design details that would otherwise help maximize efficient workflow in a home dialysis unit. Ideally, an HHD clinic's appearance should have a welcoming environment and mimic the comforts of a patient's home. Training rooms must satisfy state and local regulatory requirements. In addition, they should be spacious enough to accommodate a hemodialysis machine, appropriate water treatment and dialysate-generating equipment, a comfortable patient chair, a treatment table, cabinetry for supplies, chairs for partners and health care providers, and a desk with a computer for documentation. An open concept teaching environment may also allow for peer-to-peer support.

The organization of supplies in each training room should mimic every other training room to enable the staff to efficiently locate the equipment needed at any given time. An organized training room helps set an example and serves as a visual reminder for patients to keep their dialysis supplies organized at home. Each room should have appropriate drains and a municipal water source that is labeled appropriately to generate dialysate, rather than having the dialysate delivered, so that it can be used to model the procedures that the patients need to follow at home.

Total space requirements for a home program will vary depending upon the projected patient census. Regardless of census size, rooms and functional spaces are necessary (table 1).

Dialysis equipment — HHD can be performed with a machine specifically designed for home use or with any conventional hemodialysis machine. However, in the United States, HHD is performed with either the Fresenius 2008K@home or the NxStage home dialysis machine, which were specifically designed for HHD. A patient using the Fresenius 2008K@home is required to have a care partner, but a patient using the NxStage machine does not require a care partner for performance of hemodialysis. The NxStage machine is also approved by the US Food and Drug Administration (FDA) for nocturnal HHD. In March 2020, the Tablo Hemodialysis System was approved for use in the home in the United States. It has an integrated water purification system and provides dialysate on demand for a maximum flow rate of up to 300 mL/min.  

The Fresenius 2008K@home is similar to an ICHD machine, but smaller in size. The machine is not portable, and it requires an accompanying water treatment system (typically a reverse osmosis machine) to function. Electrical and plumbing modifications are necessary to run the dialysis machine and water treatment equipment in a patient's home. Water source may be variable and may impact the need for pretreatment equipment. Details regarding the water treatment system required for HHD is presented at length elsewhere. (See "Assuring water quality for hemodialysis", section on 'Home hemodialysis'.)

Water and electricity use can be significant and lead to an economic burden on the patient. Space limitations in a patient's home may not allow accommodation for this dialysis machine and its accompanying equipment for water treatment. However, it offers the advantage of remote monitoring of the system by the Fresenius staff, usually at an additional cost to the patient.

The NxStage machine is small, measuring approximately 15 inches high by 15 inches wide by 18 inches deep. It weighs approximately 70 pounds and can be transported in a soft case on wheels for local travel by car or a hard case with wheels for more distant travel by airplane or boat. Ultrapure dialysate is generated in the patient's home by an NxStage machine called Pureflow. It is a deionizer-based system that generates dialysate in 40-, 50-, or 60-liter batches. Water used to generate dialysate with the Pureflow system must meet US FDA Safe Drinking Water Act (SDWA) standards. Dialysate is also available in 5-liter bags for travel, in the event the Pureflow equipment is nonfunctional, or if water source (eg, well water) does not meet SDWA standards. The NxStage machine is different than a traditional ICHD machine because low volumes of dialysate are used. Its use can be supported by an NxStage iPad app, Nx2Me, which communicates with the NxStage machine and records machine data. The patient enters vital signs into the iPad and, at the end of treatment, the patient electronically transmits all the information to the dialysis unit staff. Data are not transmitted "live" or on-demand to the dialysis facility. (See "Short daily home hemodialysis: The low dialysate volume approach".)

Telemonitoring and patient safety — Telemonitoring enables remote monitoring by a data control center, which is ultimately made available for nephrologist review. Data monitored include vital signs (heart rate and blood pressure), HHD machine function, and alarms. Some state regulatory agencies might require telemonitoring.

However, the benefit of telemonitoring to ensure safety of patients at home is not clear. As an example, in the London Daily Nocturnal Hemodialysis Study, 14 nocturnal patients were monitored for a total of 4096 patient-night treatments. There were a total of 5351 registered alarms, of which 322 elicited no response or a slow response from the patient, prompting a call to the patient's home. Of the 322 calls, none required escalation of issues to a designated contact person or emergency medical services. The authors concluded that telemonitoring is most useful in the first 90 days at home until the HHD team is convinced that the patient is stable, safe, and adherent to their recommendations [2].

TRAINING OF STAFF — HHD staff includes a medical director, additional clinicians, nurses, a dialysis technician (biomedical technician), a social worker, a dietician, a patient care technician, an administrator, and an administrative assistant [3]. Some small programs may not be able to support full-time HHD staff and may share such resources with other nearby programs.

Ideally, the leadership team should include a nephrologist and nurse champions who have different yet overlapping responsibilities and skills. The nephrologist champion typically becomes the medical director of the facility. If the lead nephrologist and nurse have limited experience in HHD, they will need to devote adequate time to educate themselves by attending home dialysis meetings and courses, visiting successful home dialysis programs, and reviewing pertinent home dialysis literature. It is also extremely helpful to develop a relationship with experts at other home dialysis programs who can provide advice when needed.

Nurses have the most contact with HHD patients and need to harbor the right skill set. Superior communication and teaching skills are the most important qualities for a successful HHD nurse. Nursing experience in settings that require problem solving, having an independent thought process, and demonstrating responsible conduct are probably more important than experience in performing in-center hemodialysis (ICHD). There are also Medicare and state requirements for HHD nurses, which should be fulfilled.

The medical director has several roles, such as developing referral relationships, ensuring seamless transitions from the chronic kidney disease (CKD) clinic to the HHD clinic, providing staff education, confirming staff competency, measuring quality outcomes, supervising infection control measures, providing quality assurance, and leading continuous quality improvement projects.

A multidisciplinary approach enhances the quality of care and presents an opportunity for the staff to educate each other. Our home program mandates a multidisciplinary clinic with the nephrologist, nurses, social worker, dietician, and the program administrator. Often, staff education occurs during clinic visits, but it should also include lectures and continuing education courses. Our multidisciplinary team also meets during monthly quality assurance and patient care meetings. We recognize that each program may individualize their staffing mix, procedures, and policies. Guidance and general principles are outlined within the practical manual to enhance HHD adoption [3].

TRAINING OF THE PATIENT — Patients who perform hemodialysis at home often do so with the help of caregivers or care partners, making them an integral part of the home care team. The use of some home dialysis machines (see 'Dialysis equipment' above) mandate assistance from a partner. Thus, the training of the HHD patient described in this topic is applicable to the partner as well, as part of this home care team. Training length may be individualized and varies globally, generally ranging from 4 to 12 weeks, with one to five training sessions per week (table 2) [4].

On average, approximately 20 consecutive training sessions are required before the patient is ready to independently perform HHD. However, the training length should be individualized to the patient's understanding and skill level. Training plans specific for each patient need to be prepared by staff prior to initiation of training. Patients learn differently and it is helpful to identify a patient's learning type (visual, auditory, reading, or kinesiology/tactile) as part of the training program [5]. Some programs encourage patients to review sections of training manuals prior to initiation of training, which can improve the efficiency of training. Simulation-based training may be beneficial [6]. Patients should not be allowed to perform hemodialysis independently until the staff members are absolutely certain that the patient is safe to do so. It should also be emphasized to the patients that their training time is also when they receive their essential dialysis treatment and that missing training sessions can be detrimental to their health.

Self-cannulation training by trained in-center hemodialysis (ICHD) staff can begin weeks or even months before starting HHD training. Patients and partners are typically trained together, although the partner may skip some training sessions depending upon their intended level of involvement. Some programs train the patient only in the first week, then the patient "trains" the care partner in the second week as a way to assess skill set retention. At times, out of necessity, more than one staff member may need to train the same patient. Thus, there needs to be consistent and rigid adherence to policies and procedures, while accommodating the patient's learning style.

At the end of each week, there should be an interdisciplinary team meeting to assess patient progress and identify any concerns regarding the patient's potential to succeed at HHD (table 3). After two weeks of training, there is a more formal assessment of patient skills to determine if there are any nonmodifiable barriers to patient success that would cause the team to terminate training. As an example, if the patient routinely misses or arrives late to training sessions without prior notification, if significant short-term memory deficits are uncovered during training, or if new psychosocial barriers have surfaced in training, then it may be best to terminate training and identify other options for kidney replacement therapy.

Correct training and retraining of patients and partners is essential to guarantee patient safety in the home. Most programs train their patients in the dialysis facility. For patients who complete their training in the dialysis unit, the nurse trainer should supervise the patient at home to ensure correct set-up of equipment and uneventful completion of treatment, with a focus on safety. However, at times it may be more suitable for the patient to be trained in their own home (eg, a patient with a positive hepatitis B surface antigen will be less likely to transmit the disease to others if their training is conducted within their home, using their own equipment). The most important intervention for safe dialysis at home is a very comprehensive and effective training program that will continue when the patient is home. Adverse events during performance of HHD can be prevented by staff assessment of patient skills at regularly scheduled intervals. At every monthly clinic visit, a different safety topic is reviewed. If there are any errors or adverse events detected in the home, we have the patient visit the clinic for a focused retraining program. We observe the patient's cannulation technique, utilizing a checklist of necessary steps, every three to six months [7].

MODELS OF CARE — The care of an HHD patient may be delivered in various settings such as:

●Home dialysis facility

●Home visits

●Telemedicine and virtual ward platform

While the option of having diverse settings, such as telemedicine facilities, may improve the patient experience, some Medicare Conditions of Coverage for a home dialysis facility must be met [8]. As an example, HHD patients are required to have a physical examination by a clinician or advanced practitioner, a nursing visit, and blood tests on a monthly basis. Thus, the planning of a patient care model should take regulatory requirements into account.

BARRIERS TO IMPLEMENTATION OF HHD — Approximately 5 to 10 percent of informed dialysis patients select HHD, yet in the United States only approximately 2 percent of patients utilize an HHD modality. A symposium sponsored by the Kidney Disease Outcomes Quality Initiative (KDOQI), attended by a group of stakeholders representing health care professionals, patients, care partners, government, and industry, identified barriers and potential solutions for home dialysis initiation and maintenance [9].  

Lack of education — Patients have inadequate opportunities and options for education. Education should be available as an integral component of chronic kidney disease (CKD) care during hospitalizations and in the dialysis unit. All educational mediums, including face-to-face educational sessions, printed materials, patient-to-patient discussions, and online sources, need to be developed and enhanced. Nephrologists as team leaders need an in-depth knowledge of risks, benefits, and potential solutions to barriers as well as strong clinical skills. Fellowship program education in HHD is scant but should be mandatory. Similarly, nurses and other health care professionals should receive specialized education in HHD.

Financial — Patients and their care partners are faced with potential loss of income and increased expenses during the four- to six-hour daily training period for HHD. They may also have insufficient resources to pay for required modifications to the home. Dialysis providers incur increased supply costs for more frequent hemodialysis that is not necessarily offset by savings in facility and staff expenses, depending upon type of insurance coverage. Cost savings from decreased medication utilization and hospitalization are not realized by the dialysis providers. Dialysis providers have significant startup costs to start an HHD program and have to have confidence that they will have an appropriate return on investment. Potential income for nephrologists is higher for in-center hemodialysis (ICHD) and, therefore, in combination with potential costs of more education and clinical training, they may perceive a negative incentive for HHD.

Operational — Starting an HHD program requires new infrastructure, implementation of facility policies and procedures, regulatory approval, staff recruitment, and training that collectively can take a significant amount of time to accomplish. Small programs have small censuses, and therefore may lack the financial resources to maintain appropriate staffing; such programs may need to share staff with other HHD programs. An HHD program needs a formal agreement with an ICHD center to provide dialysis treatments in case a patient has to temporarily stop HHD.

SUMMARY AND RECOMMENDATIONS

●Growing opportunity for home hemodialysis – Home hemodialysis (HHD) has become more popular due to increased patient interest and financial incentives associated with this therapy. Consequently, the opportunity to care for HHD patients is growing. (See 'Introduction' above.)

●Physical space – A home dialysis program can be located in a new stand-alone facility, a new dialysis facility with HHD, peritoneal dialysis, and in-center hemodialysis (ICHD) infrastructure, or in the same facility as an ICHD unit by renovation of an existing unused space (table 1). (See 'Physical space' above.)

●Dialysis equipment – HHD can be performed with a machine specifically designed for home use or with any conventional hemodialysis machine. The Fresenius 2008K@home and the NxStage home dialysis machine are specifically designed for HHD. (See 'Dialysis equipment' above.)

●Remote monitoring – Telemonitoring enables remote monitoring by a data control center, which is ultimately made available for nephrologist review. Data monitored include vital signs (heart rate and blood pressure), HHD machine function, and alarms. Some regulatory agencies might require telemonitoring. However, the benefit of telemonitoring to ensure safety of patients at home is not clear. (See 'Telemonitoring and patient safety' above.)

●Staff training – HHD staff includes a medical director, additional clinicians, nurses, a dialysis technician (biomedical technician), a social worker, a dietician, a patient care technician, an administrator, and an administrative assistant. Each program may individualize their staffing mix, procedures, and policies. (See 'Training of staff' above.)

●Patient training – Patients who perform hemodialysis at home often do so with the help of caregivers or care partners. Training length may be individualized and varies globally, generally ranging from 4 to 12 weeks, with one to five training sessions per week. On average, 20 consecutive training sessions are required before the patient is ready to independently perform HHD (table 2). At the end of each week, there should be an interdisciplinary team meeting to assess patient progress and identify any concerns regarding the patient's potential to succeed at HHD (table 3). (See 'Training of the patient' above.)

●Models of care – The care of an HHD patient may be delivered in a home dialysis facility, during home visits, or a telemedicine and virtual ward platform. While the option of having diverse settings, such as telemedicine facilities, may improve the patient experience, some Medicare Conditions of Coverage for a home dialysis facility must be met. (See 'Models of care' above.)

●Barriers to home hemodialysis – Approximately 5 to 10 percent of informed dialysis patients select HHD, yet it remains an underutilized modality. There are educational, financial, and operational barriers to adoption of HHD. (See 'Barriers to implementation of HHD' above.)