Talking with Patients About Home Therapies Sherri L. Bresn BS, BSN, RN, CNN 1
This presentation is not intended to replace the medical diagnosis, and/or prescription for therapy as determined by a practicing nephrologist or physician, but to aid in having discussions as part of the healthcare team, with the patient. Please direct your patients to seek out clarity of their illness, their treatment options, and questions about their prognosis to their physician and 2 healthcare team.
Purpose of the program To review updated information about home therapies statistics and cost To help better prepare the learner, to conduct conversations with ihpatients and their families regarding home therapies 3
Objectives Explain the benefits of preserving residual renal function and how home therapies may help to retain function Discuss with patients basic information about hometherapies and theresources available Describe why patients may benefit from starting on home therapies
Profile of CKD Over 4,000 5
Profile of CKD 65,000 6
Profile of CKD 16.66 billion 7
Profile of CKD <10 8
How Many Americans have CKD? The National Kidney Foundation and CDC estimates that 20 million Americans have CKD (about one in 10 adults), and is increasing by 15% per year. 9
What is needed? Improve morbidity and mortality Improve services Manage costs Where, what, when, why and how will all these people receive treatment?
In center remains the main modality as of 2009 data Why? 11
Oversight A Brief Explanation ESRD Medicare coverage for all ages Agencies that oversee ESRD CMS Centers for Medicare and Medicaid Services Oversee guidelines for general care and provision of ESRD Spell out standards of care and patient safety Follow Conditions for Coverage Renal Network Groups under CMS State Department of Health Arm of CMS 12
Other Agencies! OSHA CDC AAMI EPA
So Why Do We Need To Know About CMS and CfC? Medicare is covering the costs for majority of dialysis patients Very limited resource Congress has proposed cutbacks and placed the system on The Bundle Home Therapies offers options as opportunities for more care to more patients
Did You KNOW? Medicare Starts Sooner With Home Therapies New Medicare patients In center no coverage for first 90 days Home modality coverage from the first day of the month Allows clinics to capture new patient pay p p py increase
Did You Know? Insurance with Home Dialysis Increased family income Increased FWB Patient continues Working Continues on Employer Insurance Increased self esteem
Treatment Options In Center Hemodialysis Conventional Nocturnal Home Dialysis Peritoneal Dialysis CAPD CCPD Incenter PD Home Hemodialysis Conventional Nocturnal Portable contained dialysis Transplant Palliative Care 17
Focus on Home Therapies Why is Home Therapies Needed? d? Need to support growing CKD population Change in Medicare reimbursement rates Offer patients independence
Focus on Physiological Benefits of Home Therapies Preservation of fresidual lrenal lfunction Those in CKD may still present with some kidney function Known as Residual Renal Function Dependent on cause and the progression Recent diagnosis of CKD generally have more residual renal function CKD over the course of several years generally y g y have less
Need for Renal Replacement Therapy and RRF Mostpatients withckd still produce urine Kidneys may still eliminate wastes and fluid but not well enough to sustain life LACK HOMEOSTASIS Dialysis therapy is prescribed when urine production is no longer sufficient
Need for Renal Replacement Therapy and RRF Patients with RRF and on Dialysis More liberal fluid intake allowance More liberal diet (sodium, potassium) Require less dialysis time or frequency Stable VS and less anemia, less ESAs
Residual Renal Function and Peritoneal Dialysis Patients with Residual Renal function do very well on PD Fluid status is more stabilized Compliance matches therapy better Diet Fluid
Effects of Peritoneal Dialysis Versus Hemodialysis on RRF Patients on PD maintain RRF longer than Hemodialysis University of Missouri study Lower decline in GFR PD minimizes hypoxia hypotension More gentle treatment
Renal Function Loss With Hemodialysis Day off Loss of RRF Fluid retention Increase waste Renal cell trauma and death hypoxia Ask your self trauma and Increase BP Do your kidney s only work 3 times a week? Rapid drop in BP Decreased blood flow to kidneys Rapid fluid and waste removal Renal Cell Death Dialysis therapy
Overview of Peritoneal Dialysis Uses lining i of abdomen (peritoneal membrane) to filter blood Soft tube is placed into the lower part of abdomen Cleansing solution (dialysate) travels through a special tube (PD catheter) into abdomen 25
Peritoneal Dialysis Catheter Surgeon places a small, soft tube called a catheter into abdomen Catheter stays in place Catheter transports the dialysate to and from peritoneal cavity (a semi permeable membrane) 26
PD Exchange Steps of an exchange Drain Fill Dwell Diffusion i Cup of Tea Osmosis Strawberry juice 1.5 % Dextrose 2.5% Dextrose 4.25% Dextrose 27
PD Therapies CAPD Continuous Ambulatory Peritoneal Dialysis CCPD Continuous Cycling Peritoneal Dialysis
CAPD Continuous Ambulatory Peritoneal Dialysis i 4 exchanges a day, 7 days a week Each exchange takes 30 to 40 minutes 4 6 times per day Each exchange uses 2 3 liters of solution Very few supplies 30 40 minutes 29
CCPD Continuous Cyclic Peritoneal Dialysis (CCPD) CCPD like CAPD except that a machine automatically fills and drains the dialysate from abdomen The machine does this at night while patient sleeps Treatments last from 10 to 12 hours every night 30
Peritoneal Dialysis Pros Performs treatment alone in flexible location when patient chooses Fewer fluid and dietary restrictions Do not need to rely on transportation to and from a clinic Less problems with fatigue and blood pressure changes Cons Exchange can disrupt daily schedule Potential for abdominal infection Peritonitis or Exit Site Infections Adequate home storage space for supplies 31
APD (Autonomic PD) Exchange Done at night while sleeping Normally 9-11 hours Will have fluid left in the morning May do one additional exchange during the day One set up for 24 hours
Peritoneal Dialysis and Diet More liberal diet and fluid restriction May need more potassium Fluid restriction is less Phosphorus still needs control Higher protein diet needed
PD Trends: Decreased Hospitalizations Hospitalizations for Hemodialysis patients have slightly increased to remaining flat Hospitalization for Peritoneal all causes have decreased 9
PD Trends: Decreased Hospitalizations Hospitalizations for Hemodialysis patients have slightly increased to remaining flat Hospitalization for Peritoneal all causes have decreased 9
Home Therapy Trends: Decreased Hospitalizations ti by Diagnosis i for Home Patients 9
Who can do PD and why? Anyone who is willing to try self care Are you interested in taking care of yourself at home? Sometimes non compliance is a cry for self control Are you interested in having more control of your day to day life? Someone who lives a distance from the clinic How long is it taking you, on a typical day to get to and from the clinic? How do you get to the clinic?
Employment and PD Someone who is working Are you currently employed? Do you like your job? Would You like to continue working? Home therapies can help maintain independence Do you need to continue to work to support your family.
Active Lifestyle and PD People with active lifestyles Do you like to visit family? Do you enjoy traveling? Are you involved in the community? What are your favorite things to do and why?
Financial Needs Ifthe patient is on disability or unemployed Do they have private insurance? Do they need financial assistance? Without insurance With PD First Ifqualify for Medicare Do not have to wait 90 days It is immediate coverage
Home Hemodialysis Provide therapy in the patient s home Can be set up using water and electricity Offers flexibility Good Adequacy BetterCompliance than in center 41
How Hemodialysis Works During treatment blood travels from the patient through the dialyzer via needles and bloodlines The dialyzer filters out wastes and extra fluids The filteredbloodflows flows through the bloodlines back to the patient 42
In Center Hemodialysis Pros Trained professionals with patient at all times Can get to know other patients Cons Treatments arescheduled by the center Must travel to the center for treatment 43
Home Hemodialysis Pros Can do it at the hours patient chooses No weekly travel to a center Sense of independence and control over treatment Cons May be stressful to family Caregiver Burnout Need several weeks of training Space for storing the machine and supplies Well or Septic issues for conventional 44
Peritoneal Dialysis VS Hemodialysis PD Waste removal via diffusion in the abdomen Fluid removal via osmosis using sugar Constantly being done More like your own kidney Requires no needles or daily blood loss No Heparin HD Waste removal via diffusion in the dialyzer Fluid removal via pressure in the dialyzer Only done 3xwk Rapid shifts unlike own kidney Requires needles with possibility of blood loss Heparin often needed
Home Patients Are Better Prepared For In Center HD Self care may lead to easier transition to HD when necessary General overall self care they tend to take better overall care of themselves Better educated dabout disease process Greater opportunity to get a permanent vascular access rather than coming with a temporary access
Talk to our patients in the beginning as part of the assessment??(www.homedialysis.org) i
Talk to our patients about the pluses and the minuses www.homedialysis.org)
Minuses
Talk To Your Patient!!!!! Home Therapies may prolong their residual renal function longer May be able to keep their jobs longer May start Medicare coverage sooner if they qualify May have less fluid and diet restrictions May be more prepared for in-center therapy when needed
Talk to our patients about Transplant Two Studies reveals both home modalities PD and HHD had a 50% better chance of getting a kidney transplant than in center Centers for Medicare and Medicate services Minneapolis Medical Research Foundation
Talk to your patients about Do they still want to work? 50% of all new patients are of working age Leads to improved patient self esteem Employer group plans Dialysis can be scheduled around work Income
Summary Work with your patients because we need to! Growing ESRD population/limited space Freedom and Flexibility Financial Stability Retention of renal function Retention of employment
References 1. Chandna SM, Farrington K. Residual renal function: Considerations on its importance and preservation in dialysis patients. Sem Dial May June;17*3):196 201,2004 2. Bargman, JM, Golper, TA. The importance of residual renal function for patients on dialysis. Nephrology Dialysis Transplantation Vol 20, Issue 4 3. Federal Registry Department of Health and Human Resources, Centers for Medicare and Medicaid Services. (2008). Conditions for coverage for end stage renal disease facilities (42 CFR Part 405, 410, 413 et al, Federal Register/Vol. 73, No. 73, Tuesday, April 15, 2008 Rules and Regulations 4.Juno Tm Matsumoto K. Clinical benefit of preserving residual renal function in patients after initiation of dialysis. Blood Purifi. 2004: 22 Suppl 2:67 71 5. Maiorca R, et al. Predictive value of dialysis adequacy and nutritional indices for mortality and morbidity in CAPD and HD patients. A longitudinal study. Nephrol Dial Transplant. Dec:10(12):2295 305,1995 6. Misra M, et al. Preservation of glomerular filtration rate on dialysis when adjusted for patient dropout. Kidney Int; Feb; 57(2): 691 6, 2000 7. Medical Education Institute, Inc. Life Options History and Philosophy: Innovation in Motion. www.lifeoptions.org/history 8. Misra M, et al. Effect of cause and time of dropout on the residual GFR: A comparative analysis of the decline of GFR on dialysis. Kidney Int; Feb; 59(2) 754 63, 2001 9. National Kidney and Urologic Disease Information Clearinghouse. National Institutes Health, National Kidney and Urologic Disease Information Clearinghouse.(2012). Kidney disease statistics for the united states (12 3895). Retrieved from NIH Publication website: www.kidney.niddk.nih.gov 10. National Institutes of Health, National Institute of Diabetes& Digestive & Kidney disease division of Kidney, Urologic, and Hemotologic Diseases. (2012). 2012 usrds annual data report volume one atlas of chronic kidney disease in the united states National Institutes of Health. 11.Snyder JJ, et al. A comparison of transplant outcomes in peritoneal dialysis and hemodialysis patients. Kidney Int;Oct;62(4):1423 30, 2002 13. Witten B, et al. Relationship of ESRD working age patient employment to treatment modality. Poster presented at the American Society of Nephrology meeting, St. Louis, MO, Otb October 31, 2004. (Abstract) t) J Am Soc Nephrol. 2004; 15:633A
Thank You Sherri L. Bresn, BS, BSN, RN, CNN Divisional Director of Home Therapies Education North Division Fresenius Medical Care North America