Patients with end-stage kidney disease (ESKD) who require dialysis often find themselves caught in what feels like an endless cycle of long dialysis sessions followed by lengthy recovery periods. Traditional dialysis, which requires travel to a dialysis clinic three times per week for treatment, has a high impact on quality of life for these patients. 

In contrast, onsite dialysis, performed at the skilled nursing facility (SNF) where a patient resides, allows for more frequent, shorter dialysis sessions (pursuant to a physician’s order). These patients no longer have to endure lengthy transportation to and from their treatments, and even better, have a faster recovery allowing them to focus on rehabilitation or other activities between sessions. 

Meet Gladys – A typical day with traditional dialysis

Residents of skilled nursing facilities who also need dialysis are often older, frail, and have multiple comorbidities. Alongside dialysis, they typically have rehabilitation activities scheduled. Traditional dialysis can take up to six hours or more to complete (including transportation to/from a dialysis center). Plus, with up to 21 hours of post-treatment recovery time, it is easy to see how a Monday-Wednesday-Friday routine could interfere with rehabilitation and daily life for these patients.

Consider the example of Gladys, a 72-year-old skilled nursing facility (SNF) resident who was discharged to the SNF from the hospital after a fall. Gladys needs physical therapy due to a hip injury sustained in her fall, and dialysis due to her End Stage Kidney Disease (ESKD). She also has a history of congestive heart failure. This is a typical day for Gladys, who is scheduled for traditional dialysis at an off-site treatment center:

• 3:30 am: The nursing staff helps Gladys get ready to go to the dialysis center for treatment. It’s Monday, so this is her first day this week. 
• 4:30 am: Gladys is waiting an hour for the patient transport van to pick her up. She rides in a wheelchair; the longer she sits in it waiting, the more pain her back and hips cause. 
• 5:00 am: Gladys arrives at the hemodialysis center, where she waits for treatment to start. She wasn’t hungry when she woke up, but now she’s missing the hot breakfast she would have received at the skilled nursing facility.
• 5:30 am: Her four-hour dialysis treatment begins. 
• 7:15 am: Gladys begins to feel nauseated and a little dizzy. She also feels a headache starting. 
• 9:30 am: Gladys is done with dialysis and is wheeled into the lobby to wait for her ride back to the skilled nursing facility. The wait is usually about an hour. In the wheelchair, her backache is now worse from sitting all day, plus she feels weak. She wishes she could lie down somewhere quiet. 
• 11:00 am: Gladys returns to her facility. Lunch is served shortly, but Gladys is too nauseous to eat more than a few bites. She returns to her room to lie down, but the usual exhaustion and dizziness she feels after a treatment seems worse today.
• 1:00 pm: It’s time for her rehab session but she still feels weak, from both the dialysis treatment and the missed meals. She also feels worried. The last time she felt this bad, her nurse was concerned about her elevated heart rate and blood pressure and sent her to the hospital for evaluation.

Meet John – A typical day with Dialyze Direct

Dialyze Direct partners with a SNF facilities to offer onsite, patient-centric dialysis in treatment “dens” to patients that exhibit co-morbidities that are deemed medically reasonable and necessary to receive more frequent dialysis (MFD). Their overall plan of care is supported and supervised by a team of experts including specially trained nurses.

John, a 75-year-old grandfather of five, has recently been transferred to a skilled nursing facility following a hospital stay due to pneumonia. He’s deconditioned from his illness, requires rehabilitation services, and has a history of ESKD. A typical day for him is as follows:

• 7:45 am: John finishes breakfast and gets ready to head to the onsite Dialyze Direct dialysis den. 
• 8:00 am: John begins his treatment which occurs at the same time Monday through Friday and lasts less than three hours. He’s brought the newspaper to read plus a few recent pictures of his grandchild to share with the nurse.  
• 11:00 am: John finishes his treatment and returns to his room for a rest before lunch. More frequent dialysis has reduced treatment recovery time for John to less than an hour. 
• 1:00 pm: John finishes his physical therapy session and heads to the community room to wait for a visit with his daughter and newborn granddaughter.  

Why are patient outcomes better with Dialyze Direct’s care model?

As illustrated by these patient stories, there is a significant difference in outcomes between traditional dialysis and MFD. Research has shown that traditional dialysis commonly results in hospital admissions on the day of treatment and that rates of sudden cardiac death following this type of dialysis are highest on Mondays. 

In contrast, MFD is gentler, resulting in fewer complications. In fact, Dialyze Direct has seen 65% fewer dialysis-related hospitalizations and a 94% reduction in vascular infections in patients receiving this model of care. In addition, MFD results in faster post-treatment recovery times. 92% of patients report recovery to baseline within 2 hours of treatment.  Lastly, onsite SNF dialysis significantly reduces patient risk of infection, including COVID-19, by eliminating exposure at the offsite dialysis center.  

Alongside these benefits to SNF patients with ESKD, there is a benefit for other key stakeholders as well. Transportation costs are reduced by 100% since patients do not need to leave the SNF for dialysis, and better patient outcomes drive high success rates with complex ESKD patients, a benefit for SNFs participating in patient-driven payment models (PDPM).

This patient population is projected to grow; currently, the rate of increase for ESKD is roughly 21,000 additional patients each year in the U.S., with Medicare devoting $80 billion a year to treating patients with chronic kidney disease.

For all reasons outlined above, MFD holds significant potential as a driver of cost-effective, improved long-term outcomes for patients. These include fewer complications, lower hospitalization rates, increased access to rehabilitation services, and quality-of-life enhancements. Because these positive results have potential to extend beyond the SNF, they merit continued investment in this modality of care. 

For more information on the Dialyze Direct difference and SNF onsite more frequent dialysis (MFD), email hello@dialyzedirect.com.

About the Author

Alice Hellebrand, DNP, RN, CNN has been with Dialyze Direct since its inception in 2015 and is responsible for overseeing the design and implementation of patient care delivery, clinical staff education, and clinical quality improvement. She has authored many journal publications and her expertise has been sought as a presenter nationally and internationally at nephrology, dialysis, and skilled nursing conferences. Her continued dedication to the Dialyze Direct model of dialysis care gives her unique insights into this pioneering approach to treatment.

There are many moving parts to consider when providing healthcare services during a natural disaster. Hospitals, nursing homes, and other providers must develop and implement emergency plans for these contingencies. In the case of dialysis, there are several important considerations: availability of dialysis equipment, filtration systems for the water used in dialysis, and the sanitation level of the water itself.

The use of in-home dialysis equipment combined with the more frequent dialysis (MFD) model for providing treatment, lends itself naturally to an adaptable approach to managing dialysis care in disaster situations. 

Dialyze Direct utilizes the NxStage system, a highly portable dialysis machine that uses far less water than conventional dialysis. Recently, during Hurricane Ian, we saw how this treatment modality, in combination with world-class staff, resulted in a tremendously positive outcome for onsite skilled nursing facility (SNF) patients enrolled in our care.

The NxStage dialysis system 

Conventional dialysis machines are bulky and require a large filtration system. They cannot be easily moved ahead of a natural disaster or easily relocated in the aftermath of one. Especially notable is the fact that they require large amounts of treated water- something that was not readily available after Hurricane Ian’s landfall.

To successfully dialyze patients with conventional dialysis during a natural disaster like Hurricane Ian, massive tanker trucks of water would be needed. With the NxStage machines, approximately 4-6 bags of pre-mixed dialysate weighing around 25 pounds are required for each treatment. During Hurricane Ian, with an appropriate emergency stock of dialysate bags, it was easy to provide safe water in quantities needed to provide treatment. This was despite boil orders in place after flooding occurred.

In addition, because the NxStage system is only 122 pounds and can be taken apart into two separate components and carried, these machines were portable enough to move to sister dialysis sites away from the storm’s direct path. In fact, in an emergency situation like a hurricane, it is possible to only move the top portion of the machine– weighing in at around 55 pounds– and the dialysate bags. In contrast, the entire filtration system and machine would be necessary with a conventional dialysis machine and weighs substantially more- as much as 300 pounds.

The onsite dialysis model

Dialyze Direct offers onsite dialysis in treatment “dens” at partner SNFs. These treatments take place five days per week (pursuant to a physician’s order), for a duration of under three hours. Because of this modality, the potential existed ahead of the hurricane to offer treatments earlier in the day than normally scheduled, in order to accommodate time for transportation to facilities away from the storm’s path. 

Additionally, in cases where patients were moved to sister facilities and scheduling had to accommodate more patients, these shorter treatment times meant that it was easier to coordinate scheduling dialysis for an increased patient census.

The benefit of a network of facilities

During Hurricane Ian, Dialyze Direct’s patients saw the immediate benefit of having access to multiple onsite options. Because the SNFs they resided in had sister facilities that also partnered with Dialyze Direct, these residents were able to be relocated, along with the NxStage equipment, to alternative SNFs for treatment. 

This process of continuing treatments was seamless, with electronic medical records transferring easily, and staff willingly relocating temporarily to assist patients with their care needs. Where other SNFs may have been forced to relocate some patients to local hospitals for care, further burdening the healthcare system and occupying beds needed for medical emergencies, Dialyze Direct patients were able to avoid hospitalizations, both during and after the disaster.

The quality of Dialyze Direct care delivery

To deliver dialysis care with the NxStage system and MFD, Dialyze Direct’s nurses and team members are specially trained. During Hurricane Ian, their unique and patient-centered care was especially highlighted, as caregivers mobilized to work both earlier and later than their usual shifts to ensure all patients received their prescribed treatments. Staff were also willing to leave their homes for extended periods to stay with patients at non-local SNFs to offer dialysis until they could be safely transferred back to their original SNFs. 

It is this dedication and innovation that is at the heart of what Dialyze Direct does. Our dialysis patients in partner SNFs can expect better recovery times and better quality of life, and as this natural disaster illustrated, continuity of care even in challenging times.

For more information on how to join more than 200 locations in 14 states in bringing the Dialyze Difference to patients, contact David Schneck, Director of Managed Care, at (718) 506-1739, or via email at dschneck@dialyzedirect.com.

About The Author

Gilda Jones, RN, CNN is a seasoned nephrology nurse who has experience spanning nearly 4 decades, from clinical care to roles as director of nursing. As  Vice President of Clinical Services for Dialyze Direct, she provides education to staff and patients, oversees patient outcomes and manages all aspects of the dialysis units for which she is responsible. She enjoys mentoring nursing staff and providing CEU programs to help nephrology nurses excel at dialysis care. 

The idea of bringing services to patients, instead of the other way around, is not a new concept. However, since the COVID-19 pandemic highlighted exposure to infection risk when transporting patients to offsite facilities, onsite dialysis at skilled nursing facilities (SNFs) has only seen increased demand.

Dialyze Direct has been providing onsite dialysis in SNFs since 2015. Currently, we serve 175 SNFs in 14 states and counting, a testament to the expertise and resources we bring to the table for SNFs desiring to implement this service at their facilities. Dialyze Direct has developed a robust strategy and a highly skilled team to create exceptional onsite dialysis care.  

This care team is highly capable of both collaborating with the SNFs they are partnered with and delivering only high-quality care to their patients. By bringing a Dialyze Direct care team to an onsite dialysis program, SNFs can have confidence that their population of end-stage kidney disease (ESKD) patients will experience excellent treatment outcomes, and that providers will have the confidence to lean on SNFs within their network for this vital service.

Meet the Dialyze Direct care team

Our comprehensive team of professionals is part of every onsite dialysis program, and our innovative approach to treatment attracts top talent in the ESKD field. Our care providers receive specialized training to address the unique needs of the dialysis patient population, especially geriatric patients. Here are the healthcare experts who provide dialysis care to ESKD patients in our partner SNFs: 

• Nephrologist- this physician is responsible for overseeing all personalized dialysis care and visiting patients either in-person or virtually.

• Registered nurse (RN)- our dialysis nurses must have previous dialysis experience to join the care team, and receive additional training with us to operate the NxStage equipment used in many of our treatment dens.

• Licensed professional nurse (LPN or LVN)- professionals who support nephrologists and RNs in providing care to dialysis patients, including medication administration.

• Patient care technicians (PCTs)- these specially certified technicians can only work on the care team post-certification. They assist the RN to begin and end treatment sessions, and monitor patients throughout, working closely with nurses to execute the plan of care.

• Social worker- an essential part of overall care planning, our dialysis social workers coordinate with SNF social workers to locate the appropriate resources for patients during their course of treatment and post-discharge in the community, including insurance coordination.

• Registered dietician (RD)- dialysis patients benefit from specialized nutritional goals including the correct fluid balance. Our RDs work closely with SNF dieticians to ensure patients’ optimal dietary needs are being met.

How the Dialyze Direct team works with the SNF 

Dialyze Direct’s care is deeply integrated with the SNF, instead of separated. Patients enjoy the benefit of walking to their treatments (if they are able) or simple wheelchair transport, instead of lengthy and expensive transportation to and from an outpatient center. 

Because we offer more frequent dialysis (MFD) in many of our locations, which is provided in shorter sessions lasting less than three hours five times per week (pursuant to a physician’s order), our patients see faster recovery times – with the majority reporting recovery in less than two hours. They experience fewer complications of dialysis and are better able to participate in activities like rehabilitation as well, thus getting them home faster.

To achieve these outcomes, our care team works closely with the SNF to coordinate patient care. There are some key elements involved in this:

• Emergency planning- we share a collaborative strategy around emergency response for patients that may need additional medical support, so that a coordinated process is in place for any significant changes in patient condition
• Patient handoff communication- careful daily patient handoff between SNF personnel and Dialyze Direct nursing takes place to ensure that details like changes in patient condition, new doctor’s orders, vital signs, patient weight and more are all relayed between the SNF and the Dialyze Direct care team
• Monthly lab reports- we share results from patient monthly labs and mid-month hemoglobin testing to reduce the need for duplicate phlebotomy by the SNF and to assist in SNF care planning 
• Shared quality meetings- Dialyze Direct is invited to participate in SNF quality meetings, where data related to patient outcomes, program performance, team communication and more can be collaboratively discussed

How the Dialyze Direct team helps hospital discharge planners

Collaborating with SNFs is only one part of the greater patient care effort coordinated by Dialyze Direct. Prior to SNF admission, we work with the SNF hospital liaisons and hospital discharge planners to facilitate patient placement. Our automated process supports the ability to expedite ESKD patients with subacute needs into SNFs for dialysis instead of hospital discharge planners struggling to find outpatient dialysis placement. 

This includes patients with comorbidities that often exclude them from outpatient treatment, necessitating longer hospital stays. For example, Dialyze Direct is able to accept ventilated and tracheostomy patients in several of our locations throughout the country.

By working closely with SNF hospital liaisons and hospital discharge planners, we are able to quickly identify and accept patients to Dialyze Direct partner SNFs with available beds, reducing the workload for these providers.

How the Dialyze Direct team works with providers

Understandably, external providers need to remain involved in their patients’ care coordination, especially since patients will need to continue their course of treatment with their primary nephrologist post-discharge from the SNF. 

Dialyze Direct recognizes this and works in collaboration with these providers, rather than in competition. Our open-door policy allows primary nephrologists to follow their patients in the SNF if they prefer, and in the event they choose to hand off care to another nephrologist in our program temporarily, we work to coordinate post-discharge follow-up with these providers so that patients can seamlessly return for care after completing their stay in the SNF.

Onsite dialysis with our care team advances treatment for all

This overall exceptionality and ability to work with SNFs, discharge planners and providers is advancing dialysis care for patients and everyone involved in their care. In the process, our care teams improve patient outcomes and reduce costs. Multiple insurers and more than 200 SNFs have trusted Dialyze Direct to help them be at the forefront of dialysis care.

To learn more about how the Dialyze Direct care model can increase quality of care at SNFs, relieve hospital capacity strain and improve patient outcomes, contact hello@dialyzedirect.com or visit www.dialyzedirect.com.

About the Author

Susan Markovich, MBA, RN, CNN is a certified nephrology nurse with more than 40 years’ experience in both critical care and nephrology. As Senior Vice President of Clinical Services at Dialyze Direct, she leads a workforce of regional managers, educators, and clinical services teams across multiple states and locations. Susan is closely involved in the mentorship and development of both clinical and non-clinical personnel and enjoys sharing her knowledge of nephrology nursing with others seeking to improve the lives of patients.