Nursing Home Program

New start dialysis is specialized in nursing home program, giving opportunities to all Nursing home centers to offer this service. At same time give the comfort to the patient to be treatment in his own bed.

The number of geriatric end-stage renal disease (ESRD) patients in the United States is increasing disproportionately to other age groups on dialysis. Thus there will be more dialysis patients that will require the assistance of nursing homes or extended care facilities. Nursing homes may be beneficial for the geriatric patient in terms of social and physical rehabilitation. Many of these facilities, however, may not take care of or may not have the capacity to adequately care for dialysis patients. Such patients have a higher rate of peritonitis when on peritoneal dialysis (PD) and have higher mortality rates on hemodialysis (HD) or PD compared to similar dialysis patients in the community. Cooperation and communication between the dialysis center and the nursing home, given the complex management issues involved in the care of these patients, are essential. One promising approach to the care of elderly dialysis patients is an integration of nursing home and dialysis unit. Although another approach could be to more fully utilize the services of adult day care centers, this has proven logistically difficult and has not been reported to be successful since it was first suggested more than a decade ago.

At the present time there are about 100,000 patients receiving dialysis therapy in the United States. Peritoneal dialysis accounts for 17,000 patients including pediatric patients. Of this group, approximately 33% are 60 years of age or older (5,600 patients).
According to the 1988 census date (1), about 5% of the geriatric population (over age 65) lives in nursing homes (1.3 million people). Approximately 0.3% of these groups (4,000) are chronic dialysis patients. Most of these patients (90%) are on hemodialysis and the remaining 10% (400 patients) are on peritoneal dialysis. Therefore, we will be focusing on a small group of patients. According to the 1984 Nursing Home Directory (2), there are 16,000 licensed facilities in the United States. With only 4,000 dialysis patients living in nursing homes, most facilities will never be exposed to ESRD patients. We can project that there will be approximately 5,000 ESRD nursing home residents by the year 2,000 and 9,700 by the year 2030. Therefore, it behooves the nephrology community to request, encourage and even pressure the nursing home industry to accept and care for these patients. By accepting the elderly for chronic dialysis care, we must also accept some responsibility for their chronic life care.

Peritoneal dialysis has a definite place in the nursing home setting. In fact, it may be more advantageous for the patient and staff if the patient was on peritoneal dialysis rather than hemodialysis. A major objection to accepting dialysis patients is transportation to a dialysis unit. Nursing home peritoneal dialysis would obviate that objection.

The dietary restrictions of the ESRD patient are not usually an issue for the CAPD patient. Nursing concerns about post-hemodialysis cardiovascular instability are not a factor in CAPD. The peritoneal dialysis patient remains in the nursing home and because of flexibility of exchange schedules, the patient is able to participate in all nursing home activities. In that regard, automated PD or nightly CCPD may be advantageous, because the patient's daytime is free and he/she is confined in their room only at night.

Let me counter other criticisms about nursing home CAPD. Nursing time is really not an issue. The total time involved in taking a weight and blood pressure and doing four exchanges is 30 to 40 minutes per day. Nursing time may actually be less with CAPD patients compared to the time associated with the post-dialysis complications. Exit site care can be given the bath or shower. Registered nurses are not the only staff members who could be trained to do exchanges. Normally, we train patients and their families to do exchanges. The final criticism is the limited storage space in the patient's room. This problem can be easily solved by the dialysis unit or possibly by more frequent deliveries by the vendor . It should of course be understood that it is the dialysis unit not the nursing home which pays for all the CAPD supplies and equipment.

Nursing home staffs are typically unfamiliar with the treatment of dialysis patients and may have a number of misconceptions and concerns. It is important to identify those concerns during the initial contact and address them through education and the development of a cooperative/supportive relationship. Once this occurs the probability of the nursing home accepting the patient (8) increases.