Case Study: Developing The First Peritoneal Dialysis Unit In A Long Term Care Setting

Originally published in 1993

With current trends in healthcare focusing on quality and cost effectiveness, the shift in the care spectrum has been from costly stays in acute care settings, to lower levels of care. Healthcare reform, advancing medical technology, and fiscal crises have all combined to bring about the emergence of subacute care. Managed care companies and insurers have become increasingly interested in the subacute care patient population. These are patients who can and should be cared for in a long-term care setting. The need exists for residential healthcare facilities (RHCFs) to develop distinct subacute care units so that these special-needs residents can receive the highest level of care possible.

The proportion of elderly patients receiving renal replacement therapy continues to increase. It has been estimated that by the year 2000, more than 60% of the U.S. end-stage renal disease (ESRD) patient population will be over 65 years of age. This ever-increasing population has more comorbid conditions and, as such, has special needs requiring a more comprehensive level of care, to be delivered by knowledgeable practitioners.

Problems such as cardiovascular instabilities or difficulty maintaining vascular accesses often make peritoneal dialysis (PD) the treatment of choice in the elderly patient. Peritoneal dialysis, in fact, provides many patients with clinical advantages over hemodialysis. For instance, many patients particularly benefit from the continuous regulation of body chemistries. Other patients with special requirements, such as those with diabetes, may realize better blood pressure and blood sugar control. Diabetics aged 20-35 actually appear to have a lower mortality risk on continuous ambulatory peritoneal dialysis (CAPD) than they do on hemodialysis.1 CAPD also provides freedom from a machine or fixed location.

Unfortunately, co-existing medical and psychosocial problems often preclude the ability of a patient to perform peritoneal dialysis in the traditional home setting. Alternative approaches, such as residency in a nursing home, are therefore required. In order to provide optimum management of ESRD services to the elderly, both dialysis and nursing home facilities need to plan for the future care of this group of patients. To that end, this article describes the process of setting up a peritoneal dialysis unit in a long-term care setting.

BACKGROUND

Haym Salomon Nursing Home is a 220-bed for-profit RHCF located in Brooklyn, NY. In 1991, recognizing the need for available nursing home placement to accommodate patients requiring peritoneal dialysis, we investigated the prospect of organizing such a unit. Prior to that time, the increased staffing requirements, high risk of infection, and the unique problems and special needs of these patients resulted in nursing homes being reticent toward accepting them. This changed when fierce competition among nursing homes to fill beds resulted in an undesirable vacancy rate in our institution. Believing that we could successfully provide the medical and psychosocial services necessary, we opened, in March 1992, the first and, to date, only dedicated peritoneal dialysis unit in the state of New York.

THE PLANNING PHASE

The entire process-from idea conception to unit completion-took some six months and, as in implementing any new project, a lot of planning. The following steps, which are listed in Table 1, comprised the planning phase.

Step 1: Step 1 was to conduct market research; that is, we determined there was a need for a PD unit in our geographic area. This was accomplished by contacting local hospitals, other nursing homes, home health agencies, dialysis centers, and insurance/managed care companies. Most nursing homes still do not accept PD patients, and the need for available placement still exists.

Step 2: Once we determined that the need existed, obtaining approval and support from all levels of staff was crucial, beginning with the owners/ board of directors. If they were not behind the program, it would not be successful. Promises of filling empty beds with clinically complex residents helped convince our owners.

Next, we needed "buy in" from the department heads who would comprise the interdisciplinary team. We presented the idea to department heads and general staff at numerous meetings. The nurses were particularly excited at the prospect of taking on a new challenge.

Last, but not least, the program had to be accepted by the current residents and their families. We presented the idea at resident and family council meetings. We had to demonstrate that it would benefit the facility, the community, and those patients who were in need of placement, all without greatly disrupting the lives of our existing resident population.

Step 3: Once our facility had made a commitment to proceed, we formalized an agreement with a dialysis center. To do so, we contacted one of the hospitals that we utilize and set up meetings with the administrative dialysis team. An official contract was not necessary, but a routine transfer agreement, detailing the basis of the relationship, was prepared which specified the following:

1. Back-up acute care services.
 

2. Routine follow-up-specifically, monthly visits, and the location of where they will occur, i.e., at the nursing home or at the hospital. (Most CAPD clinics prefer to have the residents sent there once a month since they have access to all necessary equipment, lab tests, and physicians.)
 

3. Referrals; will they be referring exclusively to our facility, and vice versa.

Step 4: Having decided on a dedicated unit versus a scatter-bed approach, staffing and training requirements were then determined. If a scatter-bed approach is taken, all staff have to be trained and utilized. With a dedicated unit, either LPNs and/or RNs can be used. At Haym Salomon, we decided from the beginning that having a designated unit with a small number of highly trained staff would increase our chances of success. Since we were actually adding nurses, we decided for cost-effectiveness that we would utilize LPNs instead of RNs. Based on our current staffing pattern-55 residents per unit, with one RN and LPN on the 7-3 and 3-11 shifts, and one RN on the 11-7 shift-and our projected case load (we started with six CAPD residents), we created two new LPN positions specifically for the CAPD unit.
Considering the dialysis schedule, which runs from 6:00 a.m.-10:00 p.m., we changed the shift times: one nurse works 6:00 a.m.-2:00 p.m., and the other, 2:00 p.m.-10:00 p.m. Since no dialysis occurs between 10:00 p.m.-6:00 a.m., we did not add another nurse. Our current night staff was able to absorb these residents. We also revised job descriptions and raised salaries to recognize increased training and skill requirements. Since LPNs are part of the bargaining unit at our facility, the discussions and changes were made with and agreed to by the union.

Step 5: If a facility decides, as we did, to set up a distinct unit, the next steps in the process deal with the physical setup.

Once we determined that our beginning capacity would be six residents, we chose a suitable area on one of the units. Room location and proximity to needed space helped make our determination. We picked two rooms to start with-one four-bed room and one two-bed room right next door. Directly across the hall was a treatment room which had to be converted to a "clean" utility room. This was to be used for storage of CAPD supplies and equipment, and as a mini-office with desk and phone. We also installed a sink for aseptic technique to be used in preparing for exchanges. Next door to this room was a porters' closet which we converted to the "soiled" utility room, complete with the necessary sink for the disposal of contaminated wastes. Last, we did some simple redecorating in the residents' rooms to help market the program and to be appealing to a generally younger population.

Step 6: Providing staff training and education came next. The hospital CAPD center, along with clinical staff from the medical supply company, provided all staff training. The first group of nurses trained included the primary CAPD LPNs, back-up and relief staff, RN supervisors (all shifts), and nursing administration. Our philosophy was that even though only selected nurses worked in the CAPD unit, as many staff as possible should be trained.

One year into the program, we provided a second training session for new nurses and any others not in the first group. The training session was a three-day intensive workshop that included both classroom (theory) and clinical demonstration. We also chose two specific nursing assistants to work in the CAPD unit. We changed their shifts, as well, to 6:00 a.m.-2:00 p.m. and 2:00 p.m.-10:00 p.m. Since the census of the CAPD unit remained at approximately 7-8, the ratio of nursing assistants to patients was consistent with standard ratios. Ongoing training includes monthly visits to the hospital CAPD facility that Haym Salomon is affiliated with, and attendance at seminars and workshops, including yearly attendance at national conventions.

Step 7: The nursing home's and hospital's administration must jointly develop policies and procedures. This includes establishment of screening procedures for referrals, determination of acceptance criteria, planning for routine and emergency follow-up care, and specific dialysis procedures.We determined that our philosophy for the CAPD unit was the same as for the general population; that is, all residents are treated as individuals, all are encouraged to maintain their independence and dignity, and all are allowed to pursue a quality of life to which they are entitled. Our mission was and is to provide a climate that is warm, home-like, comfortable, and supportive. In general, the goals and objectives of the CAPD unit must be consistent with facility-wide goals.

Step 8: Probably the most important step in the process is marketing. Any new program must be marketed, because a fantastic unit that nobody knows about will not bring about referrals.

The first thing we did was to develop an extensive mailing list which included nursing homes, hospitals, dialysis centers, home health agencies, geriatric case managers, managed care companies, and other health care organizations. We mailed out announcement cards to these agencies and persons, published ads in local newspapers, and sponsored open houses and breakfasts for discharge planners. Marketing, though, is not a one-time event. It is ongoing. Up to and including the present, we are constantly talking about, selling, and featuring our PD unit.

Step 9: This step involved making the appropriate beds available. Our social service staff helped prepare the residents and families for room changes, and as beds became available in other areas of the facility, the "non-CAPD" residents were transferred.

Unfortunately, we had to deal with having empty beds while we waited to open up all the beds in the CAPD unit. Finally, in March 1992, some six months after the idea was born, we admitted our first CAPD resident. After four months, we were filled up to our capacity of six residents. And after one and one-half years, we added two more two-bed rooms and expanded our capacity to 10. However, all CAPD beds are swing beds, which means that they can be filled with a non-CAPD resident if no CAPD resident is available. Our census in the unit fluctuates from six to nine residents, with an average of seven.

Step 10: The last step in the planning phase was establishing methods for follow-up and evaluation of patient care. To accomplish this, care was monitored through quality assurance techniques. As such, we began keeping statistics for patient days, length of stays, and infection rates. Additionally, ongoing meetings with nursing home and hospital CAPD staff helped to ensure compliance and quality of care.

THE IMPLEMENTATION PHASE

The prior discussion focused on how the CAPD unit at the Haym Salomon Nursing Home was established-a process that can be successfully followed by others. Upon completion of the planning phase, the admission process begins. Following is the sequence of steps that occur for potential admissions:

1. The nursing home receives referrals from hospitals or families via the PRI (Patient Review Instrument).
 

2. Pre-screening is crucial. The social worker and CAPD nurse personally visit and evaluate the resident in the hospital or at home. All necessary information is obtained from the hospital discharge planner or social worker.
 

3. If there is family, they are involved in the pre-screening process at this point, and their long-range goals are determined. For example, maybe they are considering eventual discharge.
 

4. The nursing home sends a copy of the PRI and any other available information to the dialysis center and in-house CAPD unit for approval.
 

5. If accepted, the resident is sent from the hospital directly to the dialysis center for initial evaluation/treatment.
 

6. The dialysis center writes orders, notes, etc. and transfers residents to the nursing home.

Ongoing Protocols:

• Regarding physician coverage, the nursing home's attending physician provides primary care and handles problems, including hospitalizations, for non-renal conditions. The nephrologist from the dialysis center provides care, writes medical orders, and decides on hospitalizations for all renal issues. The residents are seen a minimum of once per month (more often as indicated) at the dialysis clinic for a routine checkup, including physical exam, blood work, etc.
   
• Consistent and ongoing telephone communication between the nursing home CAPD staff and the dialysis facility is vital and is used to report residents' status on a routine and/or emergency basis.
   
• In order to promote continuity of care, a communication log accompanies residents during their visits to the dialysis facility.
   
• Dialysis supplies are ordered and stored on a weekly basis by the nursing home staff. They are ordered from and delivered by the medical supply company. The dialysis center functions as the provider and bills Medicare. In addition, the dialysis center provides all dialysis-related medication to the nursing home.
   
• As with all residents, the interdisciplinary team develops an individual care plan and addresses resident-specific needs pertaining to CAPD, especially renal function, diet, and medications.
   
• The recreation staff need to be creative and develop programming geared toward a younger population; for example, current video movies, more relevant crafts, etc.
   
• Regarding social services, the CAPD residents are often younger than the other residents and socially disadvantaged. They may lack family support systems or may even be homeless. As such, they require increased therapeutic and psychosocial intervention. In addition, high turnover rates directly impact on social workers. Thus, our social service department is composed of three full-time MSWs and is enhanced by the services of two psychologists.
   
• Dietitians monitor diet, intake, and weight. However, no special renal diet is required as in hemodialysis.
   
• In order to plan for a safe discharge from the facility, the interdisciplinary team develops and implements programs for teaching residents and families how to do PD at home.

OUTCOME DATA

Our program has been in effect for two and one-half years. In that time, as shown in Table 2, we have had a total of 32 admissions. Of those, two residents expired in the nursing home, 20 were discharged to hospitals and did not return, two were discharged home, and one was discharged to another nursing home. Of the 32 residents, 20 were male, 12 were female. We currently have seven residents.

The ages of the residents have ranged from 32-92, with the median age being 71. At the time of this writing, we have had a total of 6,401 patient-days, with 5,874 as in-house and 527 on bed-hold. The lengths of stays have ranged from one day to 717 days, with an average length of stay of 200 days. There have been 50 hospital admissions, and our peritonitis rate is one episode per 15 patient-months.

GOALS AND OBJECTIVES

The goals of the program were, and are, multifold: First, to fill a community need-that is, to provide available placement for a group of patients who were unable to be placed previously. Second, to fill beds. Third, we hoped to establish Haym Salomon as a dynamic, progressive facility. Secondary goals were to provide quality care in a warm, home-like environment.

We established the following criteria to measure goal-achievement:
Success in filling the community need for placement is evident through referrals. We established a log which enters data on all referrals-name of potential admission, referral source, if resident is approved for admission, and if resident is ultimately admitted or not and reasons why. Frequent and ongoing communication between Haym Salomon's administrative and admission team and hospital discharge planners/social workers is crucial and assists in attaining goals.

The goal of filling beds is measured by use of a vacancy rate formula, census data, and patient-days, and criteria to measure quality of care are expiration/discharge data, number of hospital admissions, and exit site infection and peritonitis rates.

BENEFITS AND EFFECTS

The results of our endeavor have proven extremely successful for our facility in a number of ways. We began two years ago with a six-bed unit and have since grown to 10 beds. The unit has broadened the services we offer to the community and has filled a vital need. It provides an alternative to hemodialysis, thus eliminating the need for residents to travel three times per week to a dialysis center.

Our CAPD unit has also increased staff satisfaction and motivation. The staff has risen to the challenge of dealing with this special population, which has provided an exciting change. They enjoy having the opportunity to learn new concepts, theories, and technical skills. Staff who don't work in the unit have, in fact, expressed interest in joining the program.

The program's marketing advantage has helped to fill beds and establish Haym Salomon Nursing Home as a dynamic and progressive facility. It has also helped promote our standing in the community and our relationship with other organizations. Its effect on reimbursement, however, varies. The residents can be of a younger (30-59) age group with lower-scoring ADLs (this would hinder the Case Mix Index) or older (60-90) with more clinical complexities and high-scoring ADLs. But in general, our CAPD unit has contributed to increasing, not decreasing, our reimbursement rate.

In summation, the need exists for long-term care facilities to develop special-care units. Subacute care is not just the wave of the future, it is here with us now.

Having been confronted with this need, we must rise to the occasion and help establish long-term care as an example of excellence. Facilities offering subacute care services will be successful under almost any healthcare reform plan and will be an important component of an integrated healthcare delivery network.




Reference
1. Majorca R, Vonesh EF, et al. A six-year comparison of patient and technique survival on CAPD and HD. Kid Int 34:513-524, 1988.

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