Case Study: Developing The First Peritoneal Dialysis Unit In A Long Term Care Setting
||Dr. Jodee Graifman Meddy, DO, MS, LNHA|
Co-founder of SeniorSite.com.
Dr. Jodee Meddy is a nationally acclaimed Doctor, Licensed Nursing Home Administrator and an expert on Long Term / Extended Care issues and Nursing Homes.
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.
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
- 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
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
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
- 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
- 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.
- 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.
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
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.
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.