Woman dialyzing in bed at home

Two years ago John H. Stroger Hospital, which treats some of Chicago’s poorest and most vulnerable residents, launched an in-home dialysis treatment program.  But so far, only four out of the 100 patients the Cook County-owned hospital treats for end-stage renal disease are dialyzing at home.

Nephrologist Kalyani Perumal, M.D., system director of dialysis services, told McKnight’s Home Care Daily Pulse that most of Stroger Hospital’s patients are diagnosed with ESRD when they come through the hospital’s emergency room extremely sick. That, she says, is not the ideal time to discuss home dialysis.

Kalyani Perumal, M.D. Stroger Hospital
Kalyani Perumal, M.D.

“Many of them are not in the mindset to start discussing different modalities,” Perumal explained. “All they are thinking is am I going to live?” 

Stroger Hospital’s experience reflects the myriad challenges in getting patients to dialyze at home, one year after the Centers of Medicare & Medicaid Services launched the End Stage Renal Disease Treatment Model. The payment model requires 30% of treatment providers in all 50 states to encourage home dialysis or transplants and aims to lower Medicare costs by an estimated $23 million over five-plus years.

Kidney disease is a growing problem in an aging nation. Over the past 20 years, the number of Americans with ESRD has doubled to roughly 800,000. Still, only about 15% are dialyzing at home, according to Fresenius Medical Care and DaVita Kidney Care, the nation’s two largest providers of dialysis treatment. That’s up from 12.6% in 2019, according to the United States Renal Data System.  

Barriers to home dialysis include everything from patient anxiety to logistics to a lack of in-home support. Technology is helping to address some of those problems.

Many home dialysis machines allow patients to connect virtually with clinicians who can offer support. Last year, Fresenius introduced its Kinexus Therapy Management Platform, which not only allows patients to engage with clinicians through telemedicine but also transmits patient information seamlessly between the home and clinic using a cloud-based system. However, the system requires that patients have good broadband access, which can be a problem for many rural or low-income patients.

Jeff Burbank, Fresenius
Jeff Burbank

“What we know is that if you have good broadband connectivity, you can use our whole suite of tools and capabilities and have a very different clinical outcome,” Jeff Burbank, Fresenius chief strategy and transformation officer, told McKnight’s Home Care Daily Pulse. “You are going to stay on the therapy longer and your outcomes are going to be better.” 

Although home dialysis can be more convenient for the patient, Perumal said dialyzing two to three days a week can still be physically taxing to patients with ESRD. That is why Stroger Hospital requires patients who opt for in-home treatments to have a family member or friend train on the system, so they can serve as a backup if the patient doesn’t feel well enough to operate it. However, that policy eliminates patients who don’t have a  support system.

 While Medicare and Medicaid cover the cost of home dialysis, they don’t cover the cost of home health aides to help administer the treatment. Perumal thinks CMS should address that in the ESRD payment model.

“We have a lot of home healthcare agencies going out to patients’ homes to help them with their medications,” Perumal said. “ To extend that service to assist with dialysis would be a really great benefit to our patients who want to do it, but can’t because they don’t have anyone to support them.”

Legislation introduced in Congress last fall would extend home health care assistance to dialysis patients. The Improving Access to Home Dialysis Act would provide Medicare reimbursement for trained, professional staff to assist home dialysis patients. 

Kidney care providers, such as Fresenius, are also working with value-based care providers and payers to catch patients with kidney disease earlier and educate them about the benefits of home dialysis.

“[Value-based care] allows us to work with the clinicians and create strategies to educate patients earlier,” Burbank explained. “That is tremendous in trying to debunk the concerns and challenges that patients have about in-home dialysis.”