Home dialysis requires a team effort where every member is essential for its success. The team’s responsibility is to address the patients’ medical and psychological needs, improve their understanding of the disease process and provide the required treatments to facilitate self-participation in the treatment program. The main driver of this initiative is the nephrologist – behind every great home program there is a nephrologist dedicated to support the nurses, provide education and market the home philosophy. It is expected that the nephrologist will devote sufficient time to oversee the planning, organization and direction of the program and be committed to making it work. The physician plays an active role in empowering the patient with selection of therapy. Together with their local administration, nephrologists ensure adequate infrastructure, staffing to train and care for patients and adequate training of the staff per regulatory guidelines. Unless the physician supports home therapies, the program is unlikely to grow or thrive.
The training is generally the director and coordinator of all the activities of the home program. Regardless of the size of the program, the minimum staffing required to maintain a seamless operation is two nurses: one dedicated to home training and one to fill in when the full-time nurse is absent. The nurse is the liaison with other team members to ensure continuous care and coordination, with a central role of teaching the patient to perform dialysis and manage their renal disease at home. The ideal candidate should be:
- A skilled caregiver
- An enthusiastic teacher
- Someone who enjoys the rewards associated with helping chronically-ill patients live comfortably and independently
- Comfortable evaluating, trouble-shooting and counseling patients personally and over the phone
Dietitians, social workers, surgeons and other health professionals support, fine-tune and complete patient care management. The Center for Medicare and Medicaid Services (CMS) in the US and similar organizations in other countries mandate that each home program establishes a multi-disciplinary team of healthcare professionals. Some of the roles change according to the program structure, culture and history. However, this team works together with patients and their families to understand the different modes of treatment available, how to adhere to the prescribed treatment, modify the diet and medications to individual needs, address psychosocial aspects of ESRD and to manage insurance and financial issues.
There are remarkable regional differences in the roles played by various health professionals. This is particularly true for social workers and training nurses. The specific roles are often dictated by the individual’s personality and skills, availability, local regulations and evolution of the program. Generally speaking, social workers are charged with the evaluation and documentation of the patient’s psychosocial status, assisting patients in achieving and maintaining optimal functional levels, providing financial counseling and facilitating satisfaction surveys.
Registered dietitians are an integral part of the team. Their principal responsibilities are the initial and ongoing nutritional assessment, the provision of education and tools for diet management and active participation during the care planning meetings.
The surgeon plays varying roles according to needs and established relations with the center. The skill-set of the nephrologist is a factor in determining who creates peritoneal access. However, even when catheters are mostly inserted by nephrologists, the involvement of a surgeon who knows the renal population, who is familiar with the comorbidities and complications of ERSD and is accountable for the program’s outcomes, is key to the success of the home program.