Today, at age 81, I am lying in a rehabilitation facility in Los Angeles. Several weeks ago I fell in my home, breaking my clavicle, several ribs and my hip, and began an intense regimen to regain my health. During this pandemic I am obviously concerned to be in a large healthcare setting, congregating with many people who have a weak physical constitution and are susceptible to contracting and spreading infection.
More than 30% of the early COVID-19 deaths in the U.S. as of March 16 were from a single nursing home — Life Care Center of Kirkland, Wash. Forty people in that nursing facility have died and more than two-thirds of their residents have been diagnosed with the coronavirus. We were shown the power of the virus to spread in such locations, and this has since spiraled: as of mid-April, 20% of all COVID-19 deaths in the United States were in nursing homes
Last month, Centers for Medicare and Medicaid Services administrator Seema Verma announced that all visitors were temporarily restricted from nursing homes. As CEO of Time Warner, when it was the largest media company in the world, I sat at the helm of 93,000 employees, amid constant interaction. Now I am required by federal regulations to sit here alone, and for good reason. This recipe of elderly, frail people in an enclosed communal environment is deadly.
The Centers for Disease Control and Prevention has also provided specific guidelines to address a similar deathtrap: dialysis centers, due to their comparable high volume of older patients (50% of all dialysis patients are over 65) and their history of infections are a very high risk for heightening the spread. More than 725,000 Americans suffer from kidney failure, otherwise known as end-stage renal disease (ESRD). Of these, at least 500,000 individuals are on dialysis.
Among the first two COVID-19 deaths in the U.S. were dialysis patients, and last month Fresenius, the largest dialysis provider in the US, disclosed its infection rate (less than 0.5% of its patients), which was nearly triple the per capita infection rate of the general population in the U.S. (0.17%) at the time. It is obvious — in both nursing homes and dialysis facilities — why bringing together frail and elderly patients in a bounded community during a pandemic is terrifying. With social distancing rules being impossible to observe in these treatment centers, we are likely to see more challenging containment situations.
Now imagine repeatedly cross-pollinating these vulnerable patients between two high-risk settings by taking nursing home residents to dialysis facilities several times per week and then bringing them back. Each trip exposes them to additional patients, staff and transportation workers. This could create nightmarish situations similar to Life Care Center of Kirkland across the nation.
Until recently, this would have been my fate. Like most patients on dialysis, I was traveling three times per week to an outpatient dialysis facility, exhausted for a full day in the aftermath and exposing myself to potential infections each time. Then I was privileged to begin home dialysis, and I now receive dialysis bedside in my rehabilitation facility. My exposure is only to my healthcare providers and I do not interact with any other patients. I am effectively quarantined, as someone in my current health should be.
Surprisingly, my treatment experience transformed for the better. I went from feeling like a slab of meat, thrown around anonymously in a clinic — one of the mega-dialysis duopoly’s 5,000 U.S. clinics — to a caring home treatment customized for my needs. This superior home treatment restored my vitality to such an extent that I joined Dialyze Direct, a progressive home dialysis company as Chief Mission Officer. My home dialysis experience has, on the whole, been dynamic and restorative.
However, my peers who remain traveling to and from the dialysis facility are having the opposite experience. Tens of thousands of elderly people will leave nursing homes and long-term care facilities today for a dialysis center where they will be exposed to other immunocompromised patients.
They will repeat this volatile but life-preserving tightrope walk a dozen more times this month. Even one case of coronavirus in this formula quickly snowballs into catastrophe. Every patient living in fear, pain or loneliness is a live human being needing help.
Receiving home dialysis treatments in a nursing home is not something that is only available to people like me (former CEOs). It could be provided to any patient who needs it. Unfortunately, right now it’s not available to many, which is mainly a function of the red tape and bureaucracy in healthcare. Our current system is characterized by slow decision making, limited willingness to try new and innovative therapies, and stubborn adherence to the status quo of where and how healthcare should be delivered.
President Trump signed an executive order last year that was meant to create new incentives to encourage in-home dialysis, and the Department of Health and Human Services has said it wants 80% of new ESRD patients either receiving dialysis in the home or getting a kidney transplant by 2025. I have praised the government’s landmark stance on home dialysis, but the current outbreak should not slow that down. It should accelerate it. The current providers are offering service at a higher cost and taxpayers are footing the $35 billion bill (which is 1% of the entire federal budget). Good thinking and compassion must prevail over the status quo now more than ever.
In just a matter of weeks, our country has shifted from focusing on productivity and ingenuity to a noble discussion about effective and moral distribution of resources to protect the lives of our citizens. We have so far risen to the occasion, accepting that there will be challenging consequences.
While there is much to do to suture our economy, our foremost priority has been preserving life. Many people with mild symptoms are heroically resisting the urge to go to emergency rooms to prevent the infection of healthcare workers. We are fighting our scarcity mentality at grocery stores to prevent supply chain issues. We have become makeshift home-schoolers of 30 million children to control this virus. We have all made principled sacrifices for the health of our broader community.
Many leaders in the private and public sector have given much sound advice. However, as the former CEO of large companies, and someone who has led from the top, I am aware that leaders often find out later about a disastrous weakness in our flank that only those at the bottom could anticipate.
I flatly refuse to languish at the proverbial bottom silently, rather to shout a warning: This is a time for bold action in reforming our system and our dialysis patients need it more than anyone. Our leaders must listen attentively to the story on the ground before that story is told through its tragic, broad-reaching outcomes.
We are on the precipice of a dreadful network effect between nursing homes and dialysis centers, which can cause a mass infection of our elderly, eventually affecting the broader population as well.
But there is a safer way to administer this lifesaving care, and we must urgently make plans to deliver dialysis within nursing home and long-term care facilities, and further to accelerate the provision of dialysis for those able to do it in their home. We must save our elderly and our broader population from this deadly blind spot.
With the new on-site services, the City’s public health system will now offer residents hemodialysis treatments for end stage kidney disease
On-site hemodialysis treatments will be initiated in June at NYC Health + Hospitals/Coler, and at Carter, Gouverneur, McKinney, and
Seaview by fall 2020
NYC Health + Hospitals today announced the availability of new on-site hemodialysis treatments for residents of the health system’s five post-acute care facilities who require the service and would like to receive treatments in their residence. Hemodialysis is a procedure where a dialysis machine and a special filter are used to clean a patient’s blood. With the new on-site services, the City’s public health system can now provide hemodialysis treatments for end stage kidney disease at the residential facility. Prior to offering these services on-site at NYC Health + Hospitals’ post-acute care facilities, hemodialysis patients were required to travel to other facilities for these treatments multiple times a week, becoming disruptive to the resident’s routine and contributing to higher exposure to infections. Having the services on-site provides a number of benefits to residents, including gentler dialysis sessions that help improve patients’ quality of life. Approximately 30 long-term residents will benefit from the on-site dialysis treatment. The on-site hemodialysis treatments will be initiated in June at NYC Health + Hospitals/Coler, and at Carter, Gouverneur, McKinney, and Seaview by fall 2020.
“NYC Health + Hospitals continues to make smart investments to ensure that our patients and residents have access to high-quality, comprehensive, and convenient care,” said Senior Vice President of Post-Acute Care at NYC Health + Hospitals Maureen E. McClusky, MA, LNHA, FACHE. “We are confident that this new way of delivering dialysis to our residents will improve their quality of life and overall experience at our facilities.”
“This is truly a blessing for people like me that have to get up at 3 a.m. to go to an outside dialysis center,” said a resident at NYC Health + Hospitals/Coler. “I will be able to get more rest and will improve my quality of life. I thank those from the bottom of my heart that helped make this happen.”
NYC Health + Hospitals’ post-acute care facilities will each have a designated room, referred to as a den, configured with a maximum of four dialysis chairs. Some facilities will have multiple dens to accommodate a higher volume of residents that require the hemodialysis treatments. Every patient receiving the treatment will have a uniquely assigned dialysis machine for their exclusive use and be assigned a dialysis time of their preference. Up to eight residents a day can be accommodated in each home dialysis den.
Following New York State Department of Health regulation, the hemodialysis service at NYC Health + Hospitals will be provided by Dialyze Direct, the nation’s largest provider of staff-assisted home hemodialysis in nursing homes.
According to United States Renal Data System (USRDS), in the United States, end stage kidney disease affects nearly 800,000 people, and is more prevalent among populations served by NYC Health + Hospitals. For example, USRD estimates that Hispanics are up to 2 times more likely of having end stage kidney disease than non-Hispanic populations. Approximately 550,000 people in America receive dialysis as life sustaining therapy, and the vast majority of these receive hemodialysis.
A large number of coronavirus patients are suffering kidney damage, contributing to a growing need for onsite dialysis in eldercare facilities, according to experts.
An estimated 15% of patients hospitalized for coronavirus develop acute kidney injury, according to the National Kidney Foundation. And the odds increase if a patient ends up in intensive care, with numbers rising to 20% or more. Potentially half of these patients may require dialysis, said Joseph Vassalotti, M.D., the foundation’s chief medical officer.
Data collection is ongoing, as most coronavirus patients with kidney problems are still hospitalized. As a result, the number of recovered patients who experience complete kidney failure, partial recovery or complete recovery remain unknown, Vassalotti said. But in one preprinted study by Columbia University researchers, 75% of ICU patients at a New York hospital developed acute kidney injury and 31% required dialysis.
“A whole group of people with no previous history of kidney disease now face an acute kidney injury, which brings with it an increased risk for developing chronic kidney disease,” the NKF said in a statement. “We believe this may be a looming healthcare crisis that will put a greater strain on hospitals, dialysis clinics and patients.”
Dialysis needs growing
Meanwhile, the need for hemodialysis care is growing as these patients return to eldercare facilities, according to one provider. Dialyze Direct said it’s seen an approximate 114% growth in demand for onsite home hemodialysis care within skilled nursing facilities since the start of the pandemic.
“I think it is clear that this is largely due to the havoc COVID-19 is causing to kidneys,” said Jonathan Paull, chief compliance officer.
The first spike in dialysis needs happened when some nursing homes — in collaboration with hospitals and health officials — opted to move residents to facilities that offered onsite home hemodialysis. The idea was to lessen the risk of additional viral exposure brought by travel to outpatient sites, said Paull. A more recent uptick in demand is due to the increased needs of COVID-19 survivors.
“[The] growth in demand that has occurred in just the past few months within the dialysis industry at large is equivalent to years of census growth in a non-COVID-19 pandemic world,” Paull said.
Kidney injuries tied to COVID-19 tend to be severe, with rapid increases in blood urea nitrogen and creatinine, Vassalotti said. The two leading risk factors are pre-existing kidney problems and the severity of COVID-19. Causes are varied and are thought to include extreme immune system response and inflammation, increased blood clotting, and direct kidney infection, he explained.
Some experts believe chronic kidney disease will become a lasting legacy of the coronavirus pandemic. But few Americans (17%) are currently aware that the diseases are linked, according to a Harris poll sponsored by the NKF.
Once kidneys fail, dialysis or a transplant is needed to survive.
Hear Jonathan Paull, Chief Compliance Officer speak about the dramatic impact of COVID-19 on patient kidney health
By Scott Marion | Excerpted from original version.
EDWARDSVILLE – Nursing homes and long-term care facilities are at high risk for COVID-19, but the concerns for spreading the virus become even greater when residents must leave the facilities for essential medical treatment.
Dialysis is the most common treatment that nursing home residents receive on an outpatient basis, and both nursing homes and dialysis centers are taking extra precautions to keep those residents separated from the public, especially if they have tested positive for COVID-19 or live in a facility that has had outbreaks of the virus.
“What’s happening with dialysis patients is that if they are suspected of having COVID-19, they have a dialysis center set aside so they wouldn’t be going to a regular dialysis center,” said Dr. Paul Malcharek, Internal medicine physician and associate medical director at HSHS Medical Group in Maryville. “If they are diagnosed with COVID-19, there is a different dialysis center that is set aside for them.”
People on dialysis can have weaker immune systems, making it harder to fight infections. However, kidney patients need to continue with their regularly scheduled dialysis treatments and to take necessary precautions as recommended by their healthcare team.
At least one local nursing facility, BRIA of Belleville, offers its own dialysis program through Dialyze Direct.
Jonathan Paull, general counselor and chief compliance officer for Dialyze Direct, feels that in-house dialysis is one more way to keep nursing facility residents safer during the COVID-19 pandemic.
“Geriatric patients that reside in nursing facilities are the most at-risk population in our country, and among the most at-risk in that subset are the nursing facility dialysis patients,” Paull said. “They need dialysis to survive and if their nursing facility doesn’t offer dialysis care on-site, those patients will need to go to the outpatient dialysis center three times a week.
“That means those patients are mixing with other patients from other areas at the outpatient dialysis center and then going back to their nursing facility, and that increases the risk of exposure and transmission.” In-house dialysis, on the other hand, takes away some of the uncertainty for patients who are nervous about leaving the nursing facility.
“It allows BRIA of Belleville to have a stronger quarantine in their facility and they’re reducing who is going out and who is coming back in,” Paull said. “It also serves as a great option for hospitals to discharge patients in the BRIA of Belleville facility. It provides the patient with a more comfortable setting and it also frees up hospital beds that might be needed for other patients.”
Stephanie Birch, administrator of BRIA of Belleville, believes that in-house dialysis has proved its value during the pandemic.
By Lindsay Peyton | Excerpted from original version.
Dr. John Foringer is getting a lot of calls from patients with chronic kidney disease.
His patients want to know if they are more likely than others to contract the coronavirus and whether they are susceptible to greater complications.
“We don’t know the answer yet,” said Foringer, chief of medicine at Lyndon B. Johnson Hospital and professor of internal medicine in the Division of Renal Diseases and Hypertension at UTHealth.
There isn’t yet enough data to understand specific risks or complications. But it’s not too soon to recommend that patients with kidney disease take extra precaution. As part of the larger group of patients with chronic medical conditions, they are simply at higher risk.
“I’ve been telling my patients to isolate themselves as much as they can,” Foringer said. “This is definitely a concern for them.”
Kidney patients, including those with transplants who are taking anti-rejection or immunosuppressive medicines, should take extra precautions, according to Dr. Donald Molony, a nephrologist with Memorial Hermann Texas Medical Center and professor of renal diseases and hypertension at UTHealth. He noted that individuals who are already on dialysis cannot be socially isolated if they receive regularly scheduled treatment outside of their home; if dialysis is not continued, it can jeopardize a patient’s health.
“It’s a lifesaving treatment,” Molony said.
“There is a growing acknowledgment that many patients would be best served by doing dialysis at home,” Molony said. “The problem with that is that patients who go home need to be trained. And that’s another barrier.”
Additionally, there’s a new population of individuals diagnosed with COVID-19, who develop acute kidney injury and leave the hospital in need of continued dialysis treatment.
For each group, Molony said, medical teams are taking steps to ensure that needs are met. “All of the providers are working diligently together to make sure that patients are safe,” he said.
Kidney failure and COVID-19
Acute kidney injury related to COVID-19 has been mounting, leading some researchers to question whether the coronavirus specifically targets the kidneys.
“At this stage, it’s too early to tell,” said Dr. David Sheikh-Hamad, professor of medicine-nephrology at Baylor College of Medicine.
Patients with COVID-19 develop what is known as a “cytokine storm,” or an overproduction of cytokines, due to the inflammatory response triggered by the coronavirus, Sheikh-Hamad said. This can affect multiple organs and cause leakage in blood vessels of the lungs, resulting in what is known as acute respiratory distress syndrome (ARDS), which leads to respiratory failure, Sheikh-Hamad explained. Patients with acute respiratory distress syndrome are placed on ventilators.
Listen to Jonathan Paull, Chief Compliance Officer
By Shelby Livingston | Excerpted from Original
While social distancing will help stem the spread of COVID-19, the practice is near impossible for thousands of vulnerable people who risk becoming severely ill without their regular treatment.
Patients with kidney failure are one of these vulnerable groups. Instead of keeping away from others, these patients, who tend to be older with several other chronic conditions, must visit a dialysis center to stay alive. They sit in clinics next to 10 to 30 other immunocompromised patients for four hours, three times a week. They have no choice. While other people may be able to put off scheduled doctor’s appointments to avoid infection, dialysis can’t be postponed.
“They are very fragile population and they are required to congregate,” said Dr. Daniel Weiner, a nephrologist at Tufts Medical Center. “There is no way that they can socially isolate. There’s no way that they can quarantine effectively if they are going to continue to receive their dialysis.”
Because of this, dialysis providers face the grave challenge of keeping their patients safe while in the clinic and in transit to and from their appointments. Clinics have committed to continue dialyzing patients who contract COVID-19, so as not to overwhelm hospitals that will need as many beds as possible as the pandemic worsens. Providers are also trying to assuage fear and anxiety over the virus that could cause patients to skip dialysis sessions, which would only make them more vulnerable to illness.
Roughly 750,000 people had end-stage kidney disease in 2017 and most of them were on dialysis, according to the U.S. Centers for Disease Control and Prevention. Dialysis removes waste and fluid from the blood when the kidneys are no longer working.
Seattle-based Northwest Kidney Centers has ramped up prevention and infection control procedures. It is screening patients for COVID-19 symptoms, such as fever, cough and shortness of breath, as soon as they walk in the door, said Dr. Elizabeth McNamara, chief nursing officer of the not-for-profit provider, which worked with a CDC team for the first two weeks of March. One of Northwest Kidney Centers’ patients was among the first reported U.S. deaths from COVID-19.
Patients with symptoms are given masks and clinicians use extra personal protective equipment to care for them, she said. Northwest Kidney has committed to continuing to dialyze those diagnosed with or showing signs of COVID-19 in its 19 outpatient clinics, sending them to the hospital only when there’s a clinical need. Educating patients about its strategy has helped relieve anxiety.
“We don’t want to put our patients at risk and we don’t want to overwhelm an already overwhelmed system any more,” said Dr. Suzanne Watnick, Northwest Kidney Centers’ chief medical officer. “We can protect patients probably better than if they got sent to the emergency room environment by appropriately using infection prevention and control.”
Some sources pointed out that designating certain centers for COVID-19-infected patients could promote a stigma around the disease and make it harder to staff those clinics. Coordinating transportation to a new clinic may also prove difficult.
Fiona McKinney, 59, who suffers from kidney failure and has been on dialysis for 12 years, said she feels safe at her Fresenius-owned dialysis clinic in Manhattan, New York. The clinic takes everyone’s temperature at the front door and gives each patient a mask, which they must reuse to conserve supplies. In case of a travel lockdown, the clinic armed patients with letters explaining they need to come to dialysis. When one patient at her clinic showed symptoms a little over a week ago, staff put the patient in an isolation room and called the emergency department, she said.
But McKinney has had trouble finding extra masks and knows her dialysis clinic is worried about running out. She takes a Medicare-funded car service to dialysis and is concerned that other people getting in and out of the car may be affected by the virus. She has also heard from other dialysis patients who fear going to their sessions.
“I’m definitely concerned,” McKinney said. “I do realize I’m more vulnerable being on dialysis with a low immune system, but I’m doing everything I can. I’ve seen other dialysis patients talking about making a will, but I’m not there yet.”
Providing dialysis at the patient’s home could also theoretically help prevent the spread COVID-19 while eliminating the need for transportation. Just 12% of dialysis patients receive home dialysis, though the numbers have been growing in recent years in response to support from the federal government. But before patients can be placed on home dialysis, they need weeks of training and a minor hospital procedure to place a catheter.
“I’m certain that every dialysis unit right now is trying to think how can they get patients (to dialyze) safely at home, those who could get it at home, but as the number of cases of COVID-19 increase and overwhelm our healthcare capacity at hospitals, it’s going to be more and more difficult to get procedures done,” said Dr. Holly Kramer, president of the National Kidney Foundation.
Jonathan Paull, chief compliance officer and general counsel at Dialyze Direct, provides staff-assisted dialysis in nursing facilities, said home dialysis is the solution for nursing home patients, however, and “allows for a full quarantine of the facility” during the pandemic. He argued that hospitals should be making sure to discharge dialysis patients to nursing facilities that are able to provide dialysis onsite. Nursing facilities without that capability should transfer dialysis patients to facilities with dialysis dens.
Some hospitals and nursing facilities understand that, he said, and Dialyze Direct’s roster of patients has been growing by the week.
But while most patients won’t be able to switch to dialyzing at home overnight, experts expect the COVID-19 pandemic to act as a catalyst to future uptake.
“I think that people will be able to point to what’s going on now when we emerge on the other side of this and go, hey, here’s another great reason why we need to have more home dialysis, Weiner said. “If you have other pandemics like this, if you’re on home dialysis it’s a whole lot easier to reduce your exposure than it is with coming into an in-center hemodialysis unit.
By Lyndee Yamshon | Excerpted from original version.
By waiving the three-day stay requirement for post-acute skilled nursing coverage under Medicare, the federal government has clearly indicated a desire to free up hospital beds by relying more heavily on nursing homes to provide higher-acuity services.
Residents who require routine dialysis treatments are some of the most at-risk patients — and although this population is not the current focal point, if not treated safely inside nursing home walls, they may be endangering themselves and others when traveling in and out of outpatient clinics three days per week.
“Stakeholders right now in the health care industry need to realize that dialysis patients … need to be placed in nursing facilities that have on-site home hemodialysis to reduce the exposure and transmission of the disease that is part and parcel with an outpatient dialysis center transfer,” Dialyze Direct chief compliance officer and general counsel Jonathan Paull told SNN last month, adding that as more dialysis patients are transferred to nursing homes, additional hospital beds will open up — beds very much needed during the pandemic.
The New Jersey-based Dialyze Direct offers in-house dialysis machines and staffing in nine states, and is expanding. So far, the company has seen varying responses to dialysis needs, based on region, in terms of deciding how to discharge these patients.
While some hospitals have quickly rolled out SNF-based hemodialysis strategies, with expedited government-based emergency approvals, other states show hospitals still discharging those with kidney failure back into the community.
A few states are starting to conduct more discharges to nursing homes for dialysis treatment. Paull highlighted the New York Department of Health in working to facilitate faster approvals of dialysis dens in facilities, as well as some Florida independent hospitals and nursing homes developing on-site hemodialysis initiatives.
But these programs are still too far and few between, and more needs to be done involving local departments of health and other state agencies in partnering to safeguard this population by avoiding unnecessary exposure to the virus, Paull said.
Dialyze Direct provides services in 10 states across the country, with hundreds of nursing homes as clients in each state. The company has created a telehealth model for nephrologists and their patients in order to speed up admissions and provide faster care while alleviating exposure and possible transmission of the virus.
Licensed in every state where the company provides care, the virtual program allows providers to review files, create orders, and conduct physician visits, sometimes working in tandem with registered nurses.
[Dialyze Direct] carefully screening staff and working with nursing homes to ensure they are conducting due diligence on their end. Both companies applauded their hard-working staff for showing up with a positive attitude.
“Those people are the real heroes right now that are going out there on the frontlines and providing care,” Paull said.
BROOKLYN, N.Y., May 5, 2020 /PRNewswire/ — Dialyze Direct, a leader in staff-assisted home dialysis services, announced plans for further expansion of its in-house skilled nursing dialysis service with CareRite Centers, the leading subacute and skilled nursing network within the nation. The CareRite Centers network spans from New York, New Jersey, Florida, and Tennessee; currently, Dialyze Direct operates within the CareRite network at The Chateau at Brooklyn Rehabilitation and Nursing Center in New York.
“By partnering with Dialyze Direct to provide gentler dialysis at The Chateau, our patients can avoid challenging transportation accommodations, anxiety, and long wait times at an off-site center,” shared Moshe Katz, Administrator of The Chateau. “Our patients have been empowered to participate more effectively in rehabilitation and accomplish their goals in The Chateau community with a level of vitality that is far beyond what we were used to seeing previously within this complex demographic.”
Dialyze Direct’s unique model of gentler home dialysis is particularly well-suited to elderly patients with complex comorbidities, eliminating the expensive transportation and burdensome process associated with outpatient dialysis clinics. The company’s dedicated nurses, dieticians, social workers and clinical support staff work in collaboration with the patient’s nephrologist to ensure the journey from admittance to recovery is meticulously planned for patients’ unique needs, driving significantly improved outcomes and quality of life for this demographic.
“After the implementation of the Patient Driven Payment Model (PDPM), Dialyze Direct has seen a great increase in demand for its services as SNFs shift their focus to higher-acuity residents, such as medically complex dialysis patients,” said Dialyze Direct’s COO and co-founder, Josh Rothenberg. “CareRite’s commitment to providing the best possible care for their residents aligns with our mission to improve the lives of dialysis patients across the country.”
As The Chateau is committed to providing patients with a person-centered treatment plan that focuses on the needs and wants of the individual, as all other communities in the CareRite network, this is the new benchmark for what dialysis can be and the community is happy to work with Dialyze Direct.