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By Kimberly Marselas

Federal officials on Wednesday updated guidance meant to improve the delivery of nursing home dialysis, a service many providers have been adding to attract new residents and improve quality of life for those who need the time-consuming treatments.

The Centers for Medicare & Medicaid Services issued new directions in a 21-page memo to state surveyors, who must inspect both the facilities hosting dialysis services for end-stage renal disease patients and the companies that provide equipment and should be responsible for training staff. Among the additions are stricter requirements for written agreements between dialysis providers and skilled nursing operators, to include emergency plans.

“The number of patients receiving home dialysis services in the nursing home represents a small, but growing fraction of the total population of home dialysis patients. The characteristics of this group, such as age and multiple comorbidities, increase their risk of experiencing adverse health and safety events, such as hospitalization, infection and death,” CMS noted in its memo.

“Offering home dialysis as a treatment option for nursing home residents … addresses certain disadvantages of in-center dialysis, such as transportation times and disruption of the resident’s daily activities. However, due to the dynamics of the respective care teams (i.e., nursing home and ESRD facility care teams) and the varying clinical complexities of this population, ensuring protections are in place will secure effective and safe treatments.”

Research has shown patients receiving home dialysis in nursing homes have improved clinical outcomes, improved recovery times under 2 hours, and reduced risks of infection. Providers say the approach also gives patients more time to spend in their communities socializing or receiving other needed therapies.

Jonathan Paull is general counsel and chief compliance officer for Dialyze Direct, an 8-year-old company that has become a major provider of on-site dialysis for nursing. He told McKnight’s Long-Term Care News on Wednesday that he generally supported the new standards, saying they build on CMS guidance from 2018 that “served as a tremendously helpful resource in forming standards and structures for local regulatory agencies.” 

“We know these standards work, because we have been doing them since 2015,” Paull wrote in an email. “This specialty continues to grow nationwide, and as it does, it will be critical that all providers are abiding by the highest quality and safety standards. As such, we applaud CMS in refreshing this guidance with bolstered quality and safety standards, and we believe it is a win for all stakeholders in the industry.”

Of particular concern to CMS is ensuring ongoing collaboration of care between the two providers; making sure anyone who administers the dialysis treatment — including a resident who chooses to do so himself — has received adequate training; enforcing monitoring of a patient’s status before, during and after treatment; and maintaining a “safe and sanitary environment.”

The guidance outlines more specifically what to include in written agreements for the provision of care by an end-stage renal disease facility in each nursing home it serves. Those agreements, CMS said, should address clinical details including:

Providers responsible for ‘dialysis dens’

CMS noted that patients retain the right to administer their own treatment, but said facilities must adapt if a resident’s cognitive or physical status changes over time and makes them less capable of managing the treatment or asking for help. If a resident receives dialysis in her room and is no longer able to independently request help, for example, she should have qualified dialysis personnel remain in the room throughout the entire treatment process.

The agency also reiterated dialysis providers’ responsibility for infection control in increasingly popular “dialysis dens.”

“The ESRD facility is responsible for determining that the staff’s level of skill and availability in a nursing home is adequate and the ESRD facility is responsible to ensure that home dialysis is not provided unless the safety of the patient can be guaranteed,” the memo states.

In keeping with greater emphasis on emergency planning in nursing homes, the guidance calls for additional preparedness efforts among dialysis providers working in nursing homes. Planning requirements will be expanded to include strategy for providing back-up dialysis, managing complications, navigating equipment failure and stocking emergency supplies within partner nursing homes “to prevent any delays or interruptions to a resident’s prescribed dialysis treatment.”

The guidance advances 2018 CMS instructions to surveyors, incorporating questions and feedback from state survey agencies, the dialysis provider community and other stakeholders.

“The goal of this guidance is to enable an effective and consistent approach to evaluate the quality of care and promote improvements in performance and outcomes for the nursing home dialysis population,” CMS said.

By Maggie Flynn | April 8, 2021. Find the full article here

For skilled nursing facilities, the ability to treat patients in place has far-reaching implications, perhaps most prominently in reducing unnecessary hospitalizations.

Usually that reduction is framed in terms of cost, with penalties for hospitals and SNFs alike if a patient returns to the acute care setting too soon. SNFs that perform well in preventing resident rehospitalizations can earn bonuses, for instance, through the Medicare Value-Based Purchasing (VBP) program.

But even though controversy exists around the effectiveness of that program, there are other benefits. Institutional special needs plans (I-SNPs), a Medicare Advantage program specifically for residents in long-term care facilities, have pointed to the clinical benefits of treating patients in place in any context, but particularly in times of major contagious illness where any interaction can be risky — and hospitals have sometimes been overwhelmed.

And for the residents themselves, treating in place prevents the hassle — and sometimes the trauma — of going to and from the SNF to a new setting. For some operators, dialysis services present an opportunity for SNFs to expand their ability to treat to patients in place — and find their footing in a post-COVID world.

Home hemodialysis in the skilled nursing setting would allow SNFs to avoid some of those rehospitalizations and improve patient outcomes, even before the pandemic, according to Jonathan Paull, chief compliance officer and general counsel at Dialyze Direct.

By offering this service, SNFs can attract new patients who might need it, in turn, improving their census; the operator SavaSeniorCare, for instance, sees adding dialysis services to its SNFs as a way to strengthen census even amid the changes wrought by the pandemic.

But there’s more to it even than that, Paull told SNN in late March.

“There’s another piece to it as well, what COVID has done to change the health care industry forever,” he said. “And that’s created a larger emphasis on on-site, home-based care. It put that into warp speed, because now everyone sees the benefits of what that means for the patients and for the health care industry. With the increased development of telehealth and everything that has come with that with COVID, the result is that you have a bunch of nursing facilities that are looking to move more services on site, in the nursing facility, as opposed to sending patients out for a service and bringing them back.”

With hospitals increasingly sending patients to the home rather than to the SNF setting, dialysis also provides a chance for SNFs to maximize their reimbursement under the Patient-Driven Payment Model (PDPM), which rewards providers for treating higher-acuity patients — a category that includes those who require dialysis, Josh Rothenberg, the chief operating officer and co-founder of Dialyze Direct noted.

This also makes them more vulnerable to illnesses such as COVID-19, as the Centers for Disease Control and Prevention (CDC) found in summer last year. And for dialysis patients who had to go off-site for their treatment, they had an automatic exposure risk with each trip.

“The fact is no matter how the infection control practices they tried to implement within the nursing home, there was this gap, patients that their lives depended on them going outside to a different facility and mingling with other populations and coming back to the nursing home,” Rothenberg pointed out.

Many SNFs and many states, realizing this, have started to take steps to expand their dialysis offerings. Dialyze Direct in March expanded in the state of Kentucky, after participating in a pilot program for SNF home hemodialysis run by the Bluegrass State’s Department of Health.

This was a six-month program for providers interesting in offering home hemodialysis in SNFs, with each dialysis provider allowed to start in one facility of their choice — though Rothenberg noted that he wasn’t aware of any other company participating in the pilot program. At the end of that time, the state surveyed Dialyze Direct and found it met the benchmarks and quality outcomes it was seeking, though Rothenberg and Paull told SNN they did not know which clinical indicators the state was examining.

Over the course of the pilot, Dialyze Direct worked with six patients; it is now working with a “few dozen” facilities in Kentucky, with a presence in about 125 facilities across its entire footprint: Florida, Illinois, Indiana, Kentucky, Maryland, New Jersey, New York, Ohio, Pennsylvania, Tennessee, and Texas. The company is currently expanding to an additional 170 to 180 facilities, Rothenberg said.

Dialyze Direct is planning this expansion in part because of the demand rising throughout several markets, but also because the Centers for Medicare & Medicaid Services (CMS) is focusing on expanding in-house, staff-assisted home dialysis in the nursing home, Rothenberg said.

One of the clearest indicators of that fact lies in an update to the State Operations Manual — “the Bible of nursing home surveyors,” Rothenberg noted — that CMS made a few years ago. It put an emphasis on the need to educate patients; nursing homes have to educate patients on the ability to have home dialysis on-site, and for any patients who want this service, they must either provide it or move the patient to a facility that can provide it.

For Rothenberg, this is one of the biggest signs of CMS’ focus on providing dialysis on-site.

“One nursing home owner … he told me that pre-PDPM, dialysis was another tool to be able to receive more rehab patients,” he told SNN. “Post-PDPM, it became essential in order to strengthen the financial model of the nursing facilities. Post-COVID, it became almost existential for them to have dialysis on-site.”