On-call support
The very nature of the relation between the patient and the nephrological team requires a flawless flow of information on demand. This service is traditionally provided by nurses. Access to medical records is essential. Inter-program joint efforts for on-call support by telephone or e-mail may be an efficient alternative. This initiative allows rotation of call duties and increases the pool of available experienced personnel.
Policies and procedures
Professional resources to develop appropriate clinical policies and procedures are available through industry providers and renal organizations. Most of these materials can be adopted in their entirety or adapted to meet the center’s specific needs. Networking with other professionals who have demonstrated an ability to develop a well run home program and attending site visits to centers of excellence to obtain suggestions and guidance is also helpful. Procedures for use of specific products are available from the manufacturers.
Patient training and education
Effective patient training programs can enable home patients to take control of their therapy and lives. The training process begins with an assessment of the patient’s health and ability to adhere to the disciplines of home therapy. Reimbursement practices and regulatory policies govern the training process in different countries. It is imperative to obtain the latest guidelines for your specific country or province and become thoroughly familiar with its contents in order to plan the length of training. In the US, the Physician’s Guide to Medicare Coverage of Kidney Dialysis and Kidney Transplant Services is available from CMS. Similar publications are available in other countries.
The determination of whether the training process has reached a reasonable conclusion should be made jointly by the patient and the multi-disciplinary team. Each program must formally assess the patient’s competence in performing their dialysis procedures in a safe and effective manner and provide certification of such achievement. Sample tests and training checklists are available from various professional organizations and manufacturers.
Professional education
The results of a survey conducted by Mehrotra et al. showed that 29% of US training programs had less than five PD patients per fellow and there were wide variations in the amount of time trainees spent caring for HD and PD patients1. In 14% of training programs, fellows spent less than 5% of their time receiving training for patients undergoing PD. In another survey of second year nephrology fellows in the US revealed that 50% were from programs offering 3 or fewer months of exposure to outpatient HD and 25% reported no exposure to PD2. If nephrologists are to take their appropriate place as leaders of the care delivery team, nephrology fellowships must be restructured with appropriate emphasis placed on the comprehensive care of CKD and ESRD patients. In countries where home dialysis is not being offered or with very low rates of utilization, one would not expect any training or expertise among physicians in training, thus adding physician bias due to lack of expertise and confidence to the list of deterrents to home dialysis.
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References :
- Mehrotra R, Blake P, Berman N, Nolph KD: An analysis of dialysis training in the United States and Canada. Am J Kidney Dis 2002;40:152-160.
- Nissenson AR, Agarwall R, Allon M, Cheung AK, Clark W, Depner T, Diaz-Buxo JA, Kjellstrand C, Kliger A, Martin KJ, Norris K, Ward R, Wish J. Improving outcomes in CKD and ESRD patients: Carrying the torch from training to practice. Semin Dial 2004;17:380-397.