Kidney failure is a crisis undercover in the United States. In 2018, nearly 800,000 Americans were living with end stage renal disease (ESRD for short). While the most fortunate patients are able to be cured by a functioning kidney transplant, most ESRD patients rely on an expensive, life-saving treatment called dialysis to survive. Dialysis makes up the bulk of Medicare spending in this area; in 2018, Medicare spent $49 billion on ESRD patients.
Dialysis takes place at outpatient clinics 86% of the time. This arrangement may work for active, middle-aged dialysis patients, but the majority of people in need of dialysis don’t fit that profile. In fact, 80% of ESRD patients are 65 or older, and many of them are nursing home residents.
Outpatient dialysis care is difficult on nursing home residents for several reasons. The first reason is prominent due to the coronavirus pandemic; outpatient treatment poses an infection risk for vulnerable populations. When a resident is exposed to a contagious disease at an outpatient clinic, they have the potential to expose other residents and nursing home staff to the disease as well. Furthermore, nursing home residents are often limited in their transportation options. Traveling to a dialysis clinic is disruptive and time consuming for them. Finally, some highly acute residents struggle to find placement at outpatient clinics due to their unique needs.
Were nursing homes to offer on-site dialysis, both patients and caregivers would benefit. The resident can eliminate hours of travel time per week, opening up more time for therapies and social activities that improve their quality of life. They also face decreased risk of infectious diseases. For the nursing home operators, facilities with on-site dialysis can accept higher acuity patients than those without. While installing dialysis equipment in house is an investment, operators eliminate up to $411 per trip in transportation costs by doing so. The best solutions are the ones in which every party comes out ahead.
When choosing the type of on-site dialysis to offer, nursing homes should favor 3-day treatment over daily. 98% of nursing home residents who need dialysis already receive 3-day treatments from outpatient clinics. Switching their prescription would cause confusion and may disrupt continuity of care. Additionally, daily dialysis generates more risk of missed treatments, hospitalization, or surgery. Some complications that are more likely with daily dialysis are blood clots, aneurysms, and difficulty with the blood access site. All these issues are easily avoided by offering 3-day dialysis instead of daily. On the operators’ side, 3-day dialysis is also more cost effective. For an identical upfront investment, on-site, 3-day dialysis provides treatment to 3x more patients than daily would. 6 dialysis chairs installed would support 36 patients on 3-day dialysis, but only 12 on daily dialysis.
Nursing homes need in-house dialysis care designed specially for their residents. Large dialysis providers have done a poor job accommodating their needs. Nursing home collaborations with a skilled nurse facility team would allow continuous, customized care for the silent majority: elderly ESRD patients.
