Expanding Home Hemodialysis Access: Closing the Care Partner Gap

Kidney dialysis treatments can become a full-time job for patients.

There’s transportation to the appointment, the waiting room, then around three to four hours connected to a machine, plus the ride home.

“For many patients, that’s an eight hour day,” says Jerome S. Tannenbaum, MD, PhD, FACP, Chairman and CEO of Sanderling Renal Services.

“And for a patient who is sick to start with and has other comorbid conditions like heart failure, diabetes, pressure, strokes and so forth, that becomes a really challenging day.”

These are often the patients who stand to gain the most from home hemodialysis.

They're also the patients most likely to be told they aren't good candidates for it.

Medical eligibility isn't the obstacle. A patient who could manage HHD with the right support at home may still be shut out, because no one is available to help them do it.

Most patients can’t handle inserting needles and running the machine all by themselves, especially if they have limited mobility or nerve damage from diabetes.

They need a Care Partner.

And if dialysis providers are looking to expand HHD, Care Partner availability is a necessary part of the infrastructure.

Rethinking the "ideal" home hemodialysis patient

Sanderling's results paint a different picture of the perfect home hemodialysis candidate.

“We've placed patients at home who have significant impairments," Tannenbaum says. "Some have even been on a ventilator, with a tracheostomy. Others have severe heart failure. We've had no incidents at home at all. The patients have been very stable.”

These results are meaningful because making multiple weekly trips to the clinic is hardest on these types of patients, and missing a session can come with serious health consequences.

When a patient misses a treatment, fluid builds up in the body. When the kidneys are unable to clear it, that fluid can trigger heart failure, and result in hospitalization.

But home hemodialysis can help patients avoid this.

"The hospitalization rate among those patients in our small study a few years ago was 40% less than those same patients when they were coming into the clinic," Tannenbaum says.

Rather than disqualifying patients with higher medical needs, Sanderling has focused on solving the harder problem: finding them a Care Partner.

The Care Partner gap can limit access to home hemodialysis

Finding Care Partners is easier said than done.

“Roughly 30% of our patients over 50 live alone,” Tannenbaum says. Others have a spouse or family member at home, but that person is dealing with health conditions of their own and can't take on the physical demands of dialysis.

Then there's the treatment itself. Most HHD patients need to cannulate their own fistula, inserting two needles into a blood vessel in the arm before each session.

"Most patients and their families don't really want to stick needles into someone," Tannenbaum says.

Setting up the equipment adds another layer. The machines have gotten simpler over the years, but simple isn't the same as easy for someone doing it alone for the first time.

Providers face a workforce problem, too

While expanding home hemodialysis solves one problem for patients, it creates another for providers: who covers the clinic while staff cover the home?

Gerald Roca, RN, has spent nearly 30 years in dialysis, most recently as COO of Sanderling Renal Services, where staffing in rural clinics is a constant balancing act.

Nurses and technicians are already hard to recruit, with some driving an hour or more just to get to work. Sending one of them into a patient's home for HHD support means pulling them away from a clinic floor that's already stretched thin.

Sanderling's partnership with Herewith gives providers another option. Rather than reassigning clinic staff, Sanderling can draw on Helpers sourced through Herewith and train them to support hemodialysis patients at home.

"We don't have to pull staff from the clinic to send to the patient's home," Roca says. "We can utilize [Helpers through Herewith] to take care of that."

The arrangement benefits Helpers too. "Some of those individuals have other jobs, and they want to fill the gaps around that," Roca says. "This works out for them, works out for us, and it works out for the patient as well, because everybody gets what they need."

What supported home hemodialysis can look like in practice

One Sanderling patient in Thousand Oaks, California, had reached a breaking point.

He was missing treatments. He'd been hospitalized more than once. He was managing several health conditions at the same time, and the stress was wearing him down.

"He was very depressed," Roca says. By the time the care team brought up an alternative, he was ready to give up on dialysis treatment altogether.

Then they mentioned home hemodialysis, and his whole demeanor changed. "His eyes lit up," Roca says. He wanted to know if he could do it at home, with his family there.

Sanderling and Herewith got to work: they found a Helper trained to support his treatment, got the equipment set up in his home, and created a dialysis plan built around his life instead of the clinic's schedule.

The results spoke for themselves. "The man is not missing treatments anymore," Roca says. "Hospitalizations have dropped, and he's a happy man."

Supported home hemodialysis can lower the total cost of care

A trained Care Partner costs more than an empty chair in a clinic. Tannenbaum doesn't dispute that, but he argues it's the wrong number to look at on its own.

Dialysis isn't the only cost payers cover. When a patient misses treatment and ends up in the hospital, the payer covers that cost too.

"That hospitalization can cost them two to three times the cost of the dialysis itself for the whole year," Tannenbaum says.

Set against that, the added cost of a Care Partner looks smaller. "I think the real benefit is that they can lower the total cost of care for the patient," he says.

Most providers already track hospitalization rates. This data can also make the case for supported HHD.

How Herewith helps build the human infrastructure for home dialysis

Home hemodialysis has come a long way. The machines are smaller, the technology is safer, and patients who once might have been ruled out because of complex health needs are receiving treatment at home.

But a Care Partner still has to be there to help.

Supported HHD gives providers a way to close that gap. More patients gain access to treatment at home. Patients stay on schedule instead of missing sessions.

And for people like the Thousand Oaks patient, home treatment can mean the difference between giving up on dialysis and building a routine they can live with.

"Herewith has been a great partner so far," Roca says, "and the impact they've had on our clinics and our staff has been significant."

Providers who want to expand HHD don't have to solve the Care Partner gap alone. Herewith can help you build that support into your program. Explore a home hemodialysis partnership with Herewith.