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Omar Tombocon, Peter Tregaskis, Catherine Reid, Daniella Chiappetta, Kethly Fallon, Susannah Jackson, Fiona Frawley, Dianne Peart, Ann Weston, Kim Wong, Leanne Palaster, Robert Flanc, Sandra Macdonald, Scott Wilson, Rowan Walker, Home before Hospital: a whole of system re-design project to improve rates of home-based dialysis therapy: Experience and outcomes over 8 years, International Journal for Quality in Health Care, Volume 33, Issue 3, 2021, mzab108, https://doi.org/10.1093/intqhc/mzab108
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Abstract
Despite evidence that clinical outcomes for patients treated with peritoneal dialysis (PD) or home haemodialysis are better than for patients treated with conventional satellite or hospital-based haemodialysis, rates of home-based dialysis therapies world-wide remain low. Home-based dialysis care is also cost-effective and indeed the favoured dialysis option for many patients.
Using a lean-thinking framework and established change management methodology, a project embracing a system-wide approach at making a change where a ‘Home before Hospital’ philosophy underpinned all approaches to dialysis care was undertaken. Three multidisciplinary working groups (pathway, outreach and hybrid) were established for re-design and implementation. The primary aim was to improve home-based dialysis therapy prevalence rates from a baseline of 14.8% by ≥2.5%/year to meet a target of 35%, whilst not only maintaining but improving the quality of care provided to patients requiring maintenance dialysis. A ‘future’ state pathway was developed after review of the ‘current’ state (Pathway Working Group) and formed the basis on which a nurse-led outreach service (Outreach Working Group) was established. With the support of the multidisciplinary team, the outreach service model focussed on early, consistent, and frequent education, patient support in decision-making, and clinician engagement.
A target prevalence of >30% for home-based therapies (mainly achieved with PD) was achieved within 2 years. This prevalence rate reached 35% within 3 years and was maintained at 8 years. In addition, selected patients already on maintenance satellite-based haemodialysis (Hybrid Working Group) were educated to achieve high levels of proficiencies in self-care.
Having the system-wide approach to a Quality Improvement Process and using established principles and change management processes, the successful implementation of a new sustainable model of care focussed on home-based dialysis therapy was achieved. A key feature of the model (through outreach) was early nurse-led education and support of patients in decision-making and ongoing support through multidisciplinary care.
Introduction
The cost of chronic kidney disease (CKD) and associated renal replacement therapy is a major issue for health systems around the world [1], although all home-based dialysis therapies are generally significantly cheaper than in-centre haemodialysis [2, 3]. Furthermore, despite accumulating evidence that clinical outcomes for patients treated with peritoneal dialysis (PD) or home haemodialysis are not only equivalent or even better than for patients treated with conventional in-centre haemodialysis [4, 5], actual rates of these home-based therapies remain low. Lack of feasibility has prevented conducting large prospective randomised clinical trials but evidence suggests that facilitating a home-based therapy may well improve a patient’s ability to meet the challenges of ESKD care [2] and also acknowledge that home-based care is actually the favoured dialysis option for many patients [6].
Identifying that equal or even better patient outcomes (across the age spectrum) including quality, lifestyle and economic benefits for the health system was potentially achievable through home-based renal replacement therapy [4, 7, 8], Alfred Health (AH) Network in collaboration with Peninsula Health (PH) Network (PH) embarked on a 2-year system-wide redesigning care project (envisaged in December 2011). The vision was to ensure a ‘Home before Hospital’ philosophy underpinned all approaches to dialysis care.
AH has two metropolitan-based haemodialysis satellite centres and a main-hospital in-centre unit (incorporating an acute dialysis service) and a hub and spoke partnership arrangement with PH that incorporates three additional satellite dialysis units (one metropolitan-based and two more regionally based). All satellites in both networks are located on local hospital campuses. Historically, renal service provision and patient pathways at AH and PH health networks (like most Australasian services) reflected a preference for an in-centre or satellite haemodialysis model of care (Figure 1). AH already provided haemodialysis (in-centre, satellite, and home haemodialysis), PD and transplantation as part of the renal replacement therapy options.
Methods
Study background and context
With increasing dialysis patient numbers (average increase of 3.6%/annum across both networks for the 3 years prior to the end of 2011) and being cognisant that the transition from established in-centre models of care to home-based therapies is relatively difficult [9], the most effective method to improve home-based therapy rates was perceived to be through engaging and educating patients about a home-based therapy option well before commencement of dialysis [10]. Furthermore, there was acknowledgment by both networks clinical staff (see Kotter’s Step 1; below) of potential benefits of home-based therapy that the opportunity to tailor treatment to medical and lifestyle needs to support more people in the home setting and a current model of care associated with low home-based therapy prevalence.
Project establishment, hypothesis and aims
A joint project steering and governance group (senior administrative executive sponsor, senior nurse administrator, senior nephrologist and a re-design nurse project manager (see Kotter’s Step 2; below)) was established with the approval of the executives of both networks (March 2012). This steering group proposed three collaborative initiatives that were reviewed and agreed by the combined renal nursing, physician and allied health teams across the two health networks. These initiatives ultimately formed the basis of a vision (see Kotter’s Step3; below) for a new model of ‘Home before Hospital’ care.
The first initiative was the development of a treatment pathway that prioritises and coordinates local home therapies before in-centre treatments. The second was to raise awareness of home therapy across the network regions through Nurse Outreach programs, and the third was to develop flexible individualised patient hybrid treatment plans supported by a single workforce. The hypothesis was that a whole of system pathway re-design incorporating the proposed initiatives would markedly improve prevalence rates of home-based dialysis whilst maintaining high-quality dialysis care.
In healthcare, a ‘lean-thinking’ transformational framework is a way to think about organising human actions and behaviours to deliver more benefits and maximise value for patients by eliminating/reducing waste and errors waste [11, 12]. It highlights the consideration of the patient’s needs, health worker involvement and implementation using an incremental continuous improvement philosophy. The steering group proposed that the system redesign would be based on such a framework aimed to provide new ways of working and aligned with the existing AH quality improvement methodology (Plan-Do-Study-Act Cycle) and Kotter’s 8 step change model [13] ((i) create urgency and the need for change; (ii) form a powerful guiding coalition; (iii) create a vision for change; (iv) communicate the vision for change to gain ‘buy-in’; (v) remove obstacles; (vi) create short-term wins to gain momentum; (vii) maintain momentum and (viii) incorporate the change into usual practice).
The primary aim was to develop and implement the new pathway and to improve home-based therapy prevalence rates from 14.8% (December 2011) by ≥2.5%/year. At that time, the total dialysis patient population across AH and PH services was 263 with only 39 on home-based therapies (13 on home haemodialysis and 26 on PD) (Kotter’s Step 1). The Victorian State Department of Health subsequently established state-wide targets of 35% (incident and prevalent) for home dialysis therapy in 2012–2013 for the 10 health networks with renal hub services.
Re-design project principles and timelines
Prior to detailed designing of the project, a series of overarching supporting principles were collaboratively developed and circulated by the joint-network steering and governance committee and agreed to by the clinical teams at both networks (Kotter’s Step 3).
Principle 1. A consistent model of dialysis care applied across hub and spoke.
Principle 2. Early referral and education.
Principle 3. Prioritising home therapies as first choice
(a) Home therapies default with an opt-out option.
(b) Patient choice with a focus towards PD.
(c) Incorporating urgent care (management of acute kidney injury (AKI)) and complications of therapy.
Principle 4. Providing high-level support for home therapies to patients, carers, and staff.
Principle 5. Achieving pre-specified key performance indica-tors (KPIs) for key stakeholders.
Whilst the pivotal aspiration was to improve the home-dialysis therapies rate utilising redesigning care methodology, to ensure that a whole of system redesign was realised and implemented, three project arms (three multi-disciplinary working groups) were facilitated. Member selection for the groups was by expression of interest and was based on multidisciplinary representation from across medical, nursing and allied health with representation from both networks (Kotter’s Step 2). The membership of the working groups was thought to be pivotal to the ultimate success of the project, ensuring that staff who would contribute to the change were involved in the process of designing the change. This enabled the working groups to both mentor colleagues during the transition and to own the process. The proposed project timelines are shown in the form of a GANTT chart (Figure 2).
Diagnostics
Working group 1 (Pathway-Working Group)
Re-designing the Renal Care Pathway: a treatment pathway that prioritises ‘Home before Hospital’ therapy/care
The two health networks (AH and PH) committed in principle to a 2 year redesign the model of care from an in-centre centric model to a home-based centric model of care (simplified schema shown in Figure 1). This working group, comprising one project manager, three nephrologists, six specialist renal nursing staff, one senior nurse administrator and one renal dietician, was led by the project manager. The project manager, using the lean-thinking transformational framework and Kotter’s 8 step change model lead the multi-disciplinary group in a series of workshops, forums and meetings. The processes proved to be the key to facilitating a change in the treatment paradigm that prioritised home therapies as the first option in CKD progression to dialysis by producing a shift in focus to home therapies early in the CKD trajectory and assisting all staff with keeping the project on track and engaged.
At commencement, (September 2012) the Pathway Working Group systematically reviewed and formally documented the ‘current state’ map (CKD progression to ESKD) pathway (patient journey) [14] (Kotter’s Step 3). The mapping process was again facilitated by a series of workshop sessions involving the multi-disciplinary team and led by the project manager. Throughout the project life regular up-to-date information was provided to all staff via local in-service education sessions. Project updates provided at monthly meetings, larger forums and organisational updates enhanced the depth of the communication process taking place, and regular up-to-date communication was the strategy to ensure that all stakeholders were informed (Kotter’s Step 4).
The working group’s comprehensive review of the ‘current state’ map and feedback from consumers and carers highlighted the complexity of the existing patient pathway. More importantly the review demonstrated the minimal and inconsistent patient education that occurred through all the stages of CKD progression.
Solution design
During the review of the ‘current state’, some 24 key issues under five main headings (referrals, education, communication, access to and coordination of care) that negatively influenced the patient journey and experience during CKD progression were identified. By applying the 5 principles cited above in conjunction with the lean-thinking framework, the Pathway Working Group progressively developed a more streamlined comprehensive ‘future state’ (Figure 3) that systematically addressed the 24 key issues identified in the current state map. This new renal patient pathway therefore addressed the multitude of access points, patient flow and follow up issues, including data management and monitoring that were identified as obstacles needing to be overcome (Kotter’s Step 5) in the patient journey. This process occurred over 5 months (April 2013).
In the ‘future state’ mapping, the pathway working-group also recognised the pivotal importance of facilitating PD as the main home-based dialysis modality for patients with end-stage kidney disease. The radiological (rather than surgical) insertion of Tenckhoff catheters (day procedure, local anaesthetic, easier access to the Tenckhoff catheter insertion and reduced resource requirements which had already been established) [15] was seen as an excellent opportunity to further facilitate homecare (Kotter’s Step 6).
Working group 2 (Outreach-Working Group)
Establishing a Nurse Outreach Service: raise awareness of home therapy through a Nurse Outreach Program
The new pathway (above) incorporated early referral, early and frequent (repeated) education and early decision-making regarding the patients ‘chosen pathway’ (treatment modality). Providing patients with an informed dialysis modality choice favouring ‘home’ over ‘hospital’ treatment was seen as requiring early awareness and promotion of a wider range of treatment options. Introducing a Nurse Outreach Service early in the pre-dialysis phase of the patient’s journey was perceived as more likely to provide improved planning and training for home therapy.
This working group (one project manager, one nephrologist, eight renal nursing staff and one renal dietician), through workshops, regular meetings and referencing the ‘future state’ map, designed and refined a comprehensive Renal Nurse Outreach Service that would promote training, support, and an inclusive, consistent, frequent, and proactive ‘Home before Hospital’ education. The Nurse Outreach Service team was also designed to lead the promotion of home therapies to patients and staff in both public and private setting targeting earlier stages of CKD and involving all key stakeholders.
Working group 3 (Hybrid Self-Care-Working Group)
Developing a new and innovative ‘Hybrid Self-Care’ model: Hybrid treatment plans supported by a single dialysis workforce
The Hybrid Self-Care Working Group (nine renal nursing staff and one nephrologist) worked with satellite-based patients to develop and test (also using the lean-thinking framework) a new innovative progression of care pathway model as an adjunct to the main re-designed patient journey pathway. The aim was to assist patients historically screened as ‘unsuitable’ for home therapies to potentially dialyse at home and to improve the flexibility of options for patients to benefit from home-based therapy but with increased support from a single dialysis workforce. To achieve this goal, it was anticipated that treatment would need to be individualised to patient’s medical and lifestyle needs with the intended outcome of ultimately supporting more people in the home setting or a home-like setting. It was additionally hoped that this component of the overall project might change embedded cultures by breaking down silos between satellite and home-based therapies clinical staff through a single workforce providing care in multiple settings and in turn broaden the skill set, career pathway and flexibility of the workforce.
The Hybrid Self-Care Working Group through a series of workshops and meetings defined a range of sub-models of care for satellite-based haemodialysis patients (Table 1) committing to self-managing their care. There was representation from all sites and patients through the planning, reviewing and implementation stages of the Hybrid Self-Care Dialysis model.
Self-care . | Shared care 1 . | Shared care 2 . | Nurse-managed haemodialysis . |
---|---|---|---|
Majority of home-dialysis criteria but not confident in perhaps 1–2 steps or home physically unsuitable | Patient manages up to 70% of Care | Patient manages 40% of Care | Health Professional manages 100% of care |
Weight | Health Professional manages 30% of Care | Health Professional manages 60% of Care | Patients may be able to perform 1–2 aspects of their own care e.g. open fistula pack, wash arm |
Documents | Aim to get home with nursing support | Supported in satellite unit and may not be able to transition to self-care or shared care 1 | |
Understands haemodialysis | |||
Sets up machine | |||
Sets up fistula pack | |||
Manages machine | |||
Cannulates | |||
Problem solves and trouble shoots | |||
Connects/washes-back/resuscitation | |||
Disconnects | |||
Administers medications |
Self-care . | Shared care 1 . | Shared care 2 . | Nurse-managed haemodialysis . |
---|---|---|---|
Majority of home-dialysis criteria but not confident in perhaps 1–2 steps or home physically unsuitable | Patient manages up to 70% of Care | Patient manages 40% of Care | Health Professional manages 100% of care |
Weight | Health Professional manages 30% of Care | Health Professional manages 60% of Care | Patients may be able to perform 1–2 aspects of their own care e.g. open fistula pack, wash arm |
Documents | Aim to get home with nursing support | Supported in satellite unit and may not be able to transition to self-care or shared care 1 | |
Understands haemodialysis | |||
Sets up machine | |||
Sets up fistula pack | |||
Manages machine | |||
Cannulates | |||
Problem solves and trouble shoots | |||
Connects/washes-back/resuscitation | |||
Disconnects | |||
Administers medications |
Self-care . | Shared care 1 . | Shared care 2 . | Nurse-managed haemodialysis . |
---|---|---|---|
Majority of home-dialysis criteria but not confident in perhaps 1–2 steps or home physically unsuitable | Patient manages up to 70% of Care | Patient manages 40% of Care | Health Professional manages 100% of care |
Weight | Health Professional manages 30% of Care | Health Professional manages 60% of Care | Patients may be able to perform 1–2 aspects of their own care e.g. open fistula pack, wash arm |
Documents | Aim to get home with nursing support | Supported in satellite unit and may not be able to transition to self-care or shared care 1 | |
Understands haemodialysis | |||
Sets up machine | |||
Sets up fistula pack | |||
Manages machine | |||
Cannulates | |||
Problem solves and trouble shoots | |||
Connects/washes-back/resuscitation | |||
Disconnects | |||
Administers medications |
Self-care . | Shared care 1 . | Shared care 2 . | Nurse-managed haemodialysis . |
---|---|---|---|
Majority of home-dialysis criteria but not confident in perhaps 1–2 steps or home physically unsuitable | Patient manages up to 70% of Care | Patient manages 40% of Care | Health Professional manages 100% of care |
Weight | Health Professional manages 30% of Care | Health Professional manages 60% of Care | Patients may be able to perform 1–2 aspects of their own care e.g. open fistula pack, wash arm |
Documents | Aim to get home with nursing support | Supported in satellite unit and may not be able to transition to self-care or shared care 1 | |
Understands haemodialysis | |||
Sets up machine | |||
Sets up fistula pack | |||
Manages machine | |||
Cannulates | |||
Problem solves and trouble shoots | |||
Connects/washes-back/resuscitation | |||
Disconnects | |||
Administers medications |
Implementation
With the identification of the key issues and on completion of the ‘future state’ (service) mapping, the Pathway Working Group and Renal Outreach Service Working groups led a quality improvement implementation process over 13 months (May 2014). The process was led by the Project Manager using the lean-thinking framework.
The Nurse Outreach Service progressed from a pilot (mid-2013) to an established service across both health networks (2015) (1.5 nursing eft in total). Through training, support and a comprehensive, consistent, frequent and proactive ‘Home before Hospital’ education, the nurse-led outreach service team was able to progressively promote home therapies to patients and staff in both public and private settings targeting earlier stages of CKD. The outreach team involved all key stakeholders and facilitated decision-making for patients with the support of the multi-disciplinary team (Kotter’s Step 7). Educational tools in the form of booklets and brochures for the patient were also developed and updated by the members of the outreach team to assist with consistent educational content provided to each service provider.
For patients (∼60 new patients referred annually), the focus was on one-on-one face-to-face education sessions with the outreach nurse. Sessions provided to patients (initial and subsequent) were consistently tailored to the patients/carers needs with consideration to their psychosocial, cultural, and financial needs and were repeated as necessary to meet individual needs. This also included the use of interpreters, education materials available in different languages, early referrals to social workers and other allied health team members, frequent communication, home visits and where appropriate, the offer of respite care to ameliorate the risk of carer ‘burnout’. Explanation and assistance in accessing subsidies (home dialysis patient payments, electricity concessions and essential medical equipment patient payments) available to all home dialysis patients by State and Federal Governments was also provided. It was important that patients were aware that there were no financial limitations that might lead to equity issues in their decision to access home-based dialysis care. The outreach service team also implemented the new pathway through one-on-one education sessions with all 12 nephrologists and with a series of forums for 70 renal nursing staff and renal allied health staff working across both health regions (Kotter’s Step 7).
Encouraged by the engagement of patients and staff in a pilot undertaking (2013–2015) and following significant building modifications, at one satellite haemodialysis unit (36 patients were receiving maintenance dialysis at this satellite at this time) spoked to AH, a second and ongoing Hybrid model undertaking was commenced (May 2017). Patients (already established on maintenance satellite haemodialysis) who could potentially self-manage their own dialysis care either at a satellite dialysis unit or in their own home were identified. The relevant patients were trained by the satellite staff to meet their sub-model goals and health independence was encouraged as much as possible with interested participants. A successful variation of hybrid care (combined dialysis modalities) has also been implemented where patients on PD have had supplementary treatments with haemodialysis as a bridge to transplantation.
Results
Evaluation and outcomes
The Pathway Working Group mapping process provided benefits through a multidisciplinary team approach and highlighting the key issues helped develop a broader understanding and ownership of the whole process. This was important ultimately with assisting the change management and implementation of each subsequent project component.
The effectiveness of the implementation of the nurse outreach service was evidenced by three main outcomes. First, the time between nephrologist referral to outreach and the first contact with the patient by the outreach team is <7 days in 100% of instances as of July 2020. Second, the proportion of patients referred to outreach at timelier eGFR estimates (eGFR > 20 ml/min) continues to improve. In July 2014, only 13.5% of patients referred to outreach across both health networks had eGFRs > 20 ml/min. By January 2018, the proportion was 33.0% and in July 2020, 84% had eGFRs of >20 ml/min at the time of referral. Finally, the formal education process KPI for patients at PH and AH currently equals or exceeds state-wide KPI’s [16].
The outreach outcomes combined with additional system changes to improve the access to Tenckhoff catheter insertion (as of June 2020, 70% of catheter insertions achieved by this technique) resulted in an incident rate of PD as modality of choice exceeding 50% (Figure 4). After the establishment of the model of care an annual increase well above annual expectation (2.5%/annum) from 14.8% to achieve a >30% prevalence rate for home therapy patients within 2 years was achieved (Figure 4).
The hybrid model work is ongoing but the experience in the first 34 patients is summarised (Table 2). In the pilot phase (Project 1), six of 11 (55%) of participants at some point achieved >70% self-care proficiency or were transferred to another home-based dialysis therapy or received a kidney transplant. In the second phase of hybrid evaluation (Project 2), 18 of 23 (78%) of participants achieved >70% self-care proficiency or were transferred to another home-based dialysis therapy or received a kidney transplant.
Gender . | Age . | Date commenced hybrid training . | Hybrid achievement . | Longer term outcome . |
---|---|---|---|---|
Project 1 | ||||
M | 48.6 | 8 April 2013 | Self-Care | Transplant (February 2014) |
M | 50.2 | 3 June 2013 | Self-Care | Transplant (July 2017) |
M | 64.4 | 15 April 2013 | Self-Care | Shared Care (1–2): NMH: Death (December 2018: Cardiac) |
M | 59.4 | 29 April 2013 | Self-Care | NMH: Other Health Network |
M | 57.6 | 22 April 2013 | Shared Cared (1) | Shared Cared (2) |
M | 77.5 | 6 May 2013 | Shared Cared (2) | NMH |
F | 77.6 | 21 October 2013 | Shared Cared (2) | Death (2019: Dialysis Withdrawal) |
F | 28.4 | 22 April 2013 | Shared Cared (2) | Death (2019: Dialysis Withdrawal) |
M | 67.8 | 2 August 2016 | Shared Cared (2) | Peritoneal Dx: Transplant (October 2017) |
F | 78.5 | 20 January 2014 | Shared Cared (2) | Death (October 2018 Dialysis Withdrawal) |
M | 64.7 | 23 June 2014 | Shared Cared (2) | Death (February 2019: Dialysis Withdrawal) |
Project 2 | ||||
F | 59.5 | 20 June 2017 | NMH | Peritoneal Dx: Transplant (July 2018) |
M | 37.2 | 24 October 2017 | NMH | NMH: Other Health Network |
M | 68.6 | 2 January 2018 | NMH | NMH |
M | 71.6 | 18 September 2018 | NMH | NMH: Other Health Network |
F | 33.7 | 8 May 2017 | Self-Care | Combined: Shared Cared (1) and Peritoneal Dx) |
M | 30.9 | 8 May 2017 | Self-Care | Self-Care |
M | 30.3 | 8 May 2017 | Self-Care | Self-Care: Transplant (August 2018) |
M | 54.5 | 6 June 2018 | Self-Care | Home HDx: Transplant (October 2018) |
F | 54.5 | 18 September 2018 | Self-Care | Home HDx: Death (November 2019: Dialysis withdrawal) |
M | 44.7 | 6 May 2019 | Self-Care | Home HDx: Transplant (January 2020) |
F | 46.1 | 20 January 2020 | Self-Care | Home HDx: Transplant (January 2020) |
M | 27.9 | 13 May 2020 | Shared Cared (1) | Home HDx: (Training) |
F | 67.7 | 30 May 2017 | Shared Cared (1) | Shared Cared (1) |
M | 63.3 | 15 July 2017 | Shared Cared (1) | Shared Cared (1) |
F | 50.1 | 13 October 2017 | Shared Cared (1) | Peritoneal Dx: Death (February 2018: Cardiac) |
F | 48.2 | 2 November 2017 | Shared Cared (1) | Shared Cared (1) |
M | 41.2 | 25 April 2018 | Shared Cared (1) | Shared Cared (1) |
F | 58.6 | 20 August 2018 | Shared Cared (1) | Shared Cared (1) |
M | 59.6 | 8 May 2017 | Shared Cared (2) | Shared Cared (2) |
M | 56.1 | 19 September 2017 | Shared Cared (2) | Shared Cared (2): Transplant (September 2018) |
M | 68.3 | 16 February 2018 | Shared Cared (2) | Shared Cared (2): Transplant (January 2020) |
M | 25.2 | 20 July 2018 | Shared Cared (2) | Shared Cared (2): NMH (Other Health Network) |
M | 46.2 | 29 October 2018 | Shared Cared (2) | Shared Cared (2): Transplant (April 2019) |
Gender . | Age . | Date commenced hybrid training . | Hybrid achievement . | Longer term outcome . |
---|---|---|---|---|
Project 1 | ||||
M | 48.6 | 8 April 2013 | Self-Care | Transplant (February 2014) |
M | 50.2 | 3 June 2013 | Self-Care | Transplant (July 2017) |
M | 64.4 | 15 April 2013 | Self-Care | Shared Care (1–2): NMH: Death (December 2018: Cardiac) |
M | 59.4 | 29 April 2013 | Self-Care | NMH: Other Health Network |
M | 57.6 | 22 April 2013 | Shared Cared (1) | Shared Cared (2) |
M | 77.5 | 6 May 2013 | Shared Cared (2) | NMH |
F | 77.6 | 21 October 2013 | Shared Cared (2) | Death (2019: Dialysis Withdrawal) |
F | 28.4 | 22 April 2013 | Shared Cared (2) | Death (2019: Dialysis Withdrawal) |
M | 67.8 | 2 August 2016 | Shared Cared (2) | Peritoneal Dx: Transplant (October 2017) |
F | 78.5 | 20 January 2014 | Shared Cared (2) | Death (October 2018 Dialysis Withdrawal) |
M | 64.7 | 23 June 2014 | Shared Cared (2) | Death (February 2019: Dialysis Withdrawal) |
Project 2 | ||||
F | 59.5 | 20 June 2017 | NMH | Peritoneal Dx: Transplant (July 2018) |
M | 37.2 | 24 October 2017 | NMH | NMH: Other Health Network |
M | 68.6 | 2 January 2018 | NMH | NMH |
M | 71.6 | 18 September 2018 | NMH | NMH: Other Health Network |
F | 33.7 | 8 May 2017 | Self-Care | Combined: Shared Cared (1) and Peritoneal Dx) |
M | 30.9 | 8 May 2017 | Self-Care | Self-Care |
M | 30.3 | 8 May 2017 | Self-Care | Self-Care: Transplant (August 2018) |
M | 54.5 | 6 June 2018 | Self-Care | Home HDx: Transplant (October 2018) |
F | 54.5 | 18 September 2018 | Self-Care | Home HDx: Death (November 2019: Dialysis withdrawal) |
M | 44.7 | 6 May 2019 | Self-Care | Home HDx: Transplant (January 2020) |
F | 46.1 | 20 January 2020 | Self-Care | Home HDx: Transplant (January 2020) |
M | 27.9 | 13 May 2020 | Shared Cared (1) | Home HDx: (Training) |
F | 67.7 | 30 May 2017 | Shared Cared (1) | Shared Cared (1) |
M | 63.3 | 15 July 2017 | Shared Cared (1) | Shared Cared (1) |
F | 50.1 | 13 October 2017 | Shared Cared (1) | Peritoneal Dx: Death (February 2018: Cardiac) |
F | 48.2 | 2 November 2017 | Shared Cared (1) | Shared Cared (1) |
M | 41.2 | 25 April 2018 | Shared Cared (1) | Shared Cared (1) |
F | 58.6 | 20 August 2018 | Shared Cared (1) | Shared Cared (1) |
M | 59.6 | 8 May 2017 | Shared Cared (2) | Shared Cared (2) |
M | 56.1 | 19 September 2017 | Shared Cared (2) | Shared Cared (2): Transplant (September 2018) |
M | 68.3 | 16 February 2018 | Shared Cared (2) | Shared Cared (2): Transplant (January 2020) |
M | 25.2 | 20 July 2018 | Shared Cared (2) | Shared Cared (2): NMH (Other Health Network) |
M | 46.2 | 29 October 2018 | Shared Cared (2) | Shared Cared (2): Transplant (April 2019) |
Home HDx, home haemodialysis; NMH, nurse-managed haemodialysis; peritoneal DX, peritoneal dialysis.
Gender . | Age . | Date commenced hybrid training . | Hybrid achievement . | Longer term outcome . |
---|---|---|---|---|
Project 1 | ||||
M | 48.6 | 8 April 2013 | Self-Care | Transplant (February 2014) |
M | 50.2 | 3 June 2013 | Self-Care | Transplant (July 2017) |
M | 64.4 | 15 April 2013 | Self-Care | Shared Care (1–2): NMH: Death (December 2018: Cardiac) |
M | 59.4 | 29 April 2013 | Self-Care | NMH: Other Health Network |
M | 57.6 | 22 April 2013 | Shared Cared (1) | Shared Cared (2) |
M | 77.5 | 6 May 2013 | Shared Cared (2) | NMH |
F | 77.6 | 21 October 2013 | Shared Cared (2) | Death (2019: Dialysis Withdrawal) |
F | 28.4 | 22 April 2013 | Shared Cared (2) | Death (2019: Dialysis Withdrawal) |
M | 67.8 | 2 August 2016 | Shared Cared (2) | Peritoneal Dx: Transplant (October 2017) |
F | 78.5 | 20 January 2014 | Shared Cared (2) | Death (October 2018 Dialysis Withdrawal) |
M | 64.7 | 23 June 2014 | Shared Cared (2) | Death (February 2019: Dialysis Withdrawal) |
Project 2 | ||||
F | 59.5 | 20 June 2017 | NMH | Peritoneal Dx: Transplant (July 2018) |
M | 37.2 | 24 October 2017 | NMH | NMH: Other Health Network |
M | 68.6 | 2 January 2018 | NMH | NMH |
M | 71.6 | 18 September 2018 | NMH | NMH: Other Health Network |
F | 33.7 | 8 May 2017 | Self-Care | Combined: Shared Cared (1) and Peritoneal Dx) |
M | 30.9 | 8 May 2017 | Self-Care | Self-Care |
M | 30.3 | 8 May 2017 | Self-Care | Self-Care: Transplant (August 2018) |
M | 54.5 | 6 June 2018 | Self-Care | Home HDx: Transplant (October 2018) |
F | 54.5 | 18 September 2018 | Self-Care | Home HDx: Death (November 2019: Dialysis withdrawal) |
M | 44.7 | 6 May 2019 | Self-Care | Home HDx: Transplant (January 2020) |
F | 46.1 | 20 January 2020 | Self-Care | Home HDx: Transplant (January 2020) |
M | 27.9 | 13 May 2020 | Shared Cared (1) | Home HDx: (Training) |
F | 67.7 | 30 May 2017 | Shared Cared (1) | Shared Cared (1) |
M | 63.3 | 15 July 2017 | Shared Cared (1) | Shared Cared (1) |
F | 50.1 | 13 October 2017 | Shared Cared (1) | Peritoneal Dx: Death (February 2018: Cardiac) |
F | 48.2 | 2 November 2017 | Shared Cared (1) | Shared Cared (1) |
M | 41.2 | 25 April 2018 | Shared Cared (1) | Shared Cared (1) |
F | 58.6 | 20 August 2018 | Shared Cared (1) | Shared Cared (1) |
M | 59.6 | 8 May 2017 | Shared Cared (2) | Shared Cared (2) |
M | 56.1 | 19 September 2017 | Shared Cared (2) | Shared Cared (2): Transplant (September 2018) |
M | 68.3 | 16 February 2018 | Shared Cared (2) | Shared Cared (2): Transplant (January 2020) |
M | 25.2 | 20 July 2018 | Shared Cared (2) | Shared Cared (2): NMH (Other Health Network) |
M | 46.2 | 29 October 2018 | Shared Cared (2) | Shared Cared (2): Transplant (April 2019) |
Gender . | Age . | Date commenced hybrid training . | Hybrid achievement . | Longer term outcome . |
---|---|---|---|---|
Project 1 | ||||
M | 48.6 | 8 April 2013 | Self-Care | Transplant (February 2014) |
M | 50.2 | 3 June 2013 | Self-Care | Transplant (July 2017) |
M | 64.4 | 15 April 2013 | Self-Care | Shared Care (1–2): NMH: Death (December 2018: Cardiac) |
M | 59.4 | 29 April 2013 | Self-Care | NMH: Other Health Network |
M | 57.6 | 22 April 2013 | Shared Cared (1) | Shared Cared (2) |
M | 77.5 | 6 May 2013 | Shared Cared (2) | NMH |
F | 77.6 | 21 October 2013 | Shared Cared (2) | Death (2019: Dialysis Withdrawal) |
F | 28.4 | 22 April 2013 | Shared Cared (2) | Death (2019: Dialysis Withdrawal) |
M | 67.8 | 2 August 2016 | Shared Cared (2) | Peritoneal Dx: Transplant (October 2017) |
F | 78.5 | 20 January 2014 | Shared Cared (2) | Death (October 2018 Dialysis Withdrawal) |
M | 64.7 | 23 June 2014 | Shared Cared (2) | Death (February 2019: Dialysis Withdrawal) |
Project 2 | ||||
F | 59.5 | 20 June 2017 | NMH | Peritoneal Dx: Transplant (July 2018) |
M | 37.2 | 24 October 2017 | NMH | NMH: Other Health Network |
M | 68.6 | 2 January 2018 | NMH | NMH |
M | 71.6 | 18 September 2018 | NMH | NMH: Other Health Network |
F | 33.7 | 8 May 2017 | Self-Care | Combined: Shared Cared (1) and Peritoneal Dx) |
M | 30.9 | 8 May 2017 | Self-Care | Self-Care |
M | 30.3 | 8 May 2017 | Self-Care | Self-Care: Transplant (August 2018) |
M | 54.5 | 6 June 2018 | Self-Care | Home HDx: Transplant (October 2018) |
F | 54.5 | 18 September 2018 | Self-Care | Home HDx: Death (November 2019: Dialysis withdrawal) |
M | 44.7 | 6 May 2019 | Self-Care | Home HDx: Transplant (January 2020) |
F | 46.1 | 20 January 2020 | Self-Care | Home HDx: Transplant (January 2020) |
M | 27.9 | 13 May 2020 | Shared Cared (1) | Home HDx: (Training) |
F | 67.7 | 30 May 2017 | Shared Cared (1) | Shared Cared (1) |
M | 63.3 | 15 July 2017 | Shared Cared (1) | Shared Cared (1) |
F | 50.1 | 13 October 2017 | Shared Cared (1) | Peritoneal Dx: Death (February 2018: Cardiac) |
F | 48.2 | 2 November 2017 | Shared Cared (1) | Shared Cared (1) |
M | 41.2 | 25 April 2018 | Shared Cared (1) | Shared Cared (1) |
F | 58.6 | 20 August 2018 | Shared Cared (1) | Shared Cared (1) |
M | 59.6 | 8 May 2017 | Shared Cared (2) | Shared Cared (2) |
M | 56.1 | 19 September 2017 | Shared Cared (2) | Shared Cared (2): Transplant (September 2018) |
M | 68.3 | 16 February 2018 | Shared Cared (2) | Shared Cared (2): Transplant (January 2020) |
M | 25.2 | 20 July 2018 | Shared Cared (2) | Shared Cared (2): NMH (Other Health Network) |
M | 46.2 | 29 October 2018 | Shared Cared (2) | Shared Cared (2): Transplant (April 2019) |
Home HDx, home haemodialysis; NMH, nurse-managed haemodialysis; peritoneal DX, peritoneal dialysis.
The current single site proactive approach has helped identify further challenges, including the potential impacts on existing funding models for satellite dialysis care using a Hybrid self-care model. Anticipated future outcomes and aspirations to be explored include the identification of further self-management training opportunities for all satellite dialysis patients, increasing dialysis nursing staff satisfaction through adoption of new skills and the retention of specialist renal nursing staff at AH and PH services through innovative workforce models.
Sustainability
By incorporating robust redesign methodology, changes in the Renal Care Pathway, the establishment of the Nurse Outreach Team at both networks and preliminary work with the Hybrid model the model of care was effectively incorporated into daily practice as the standard of care over both networks over 2 years (Kotter’s Step 8). Outcome measures showed home dialysis prevalence rates sustained at close to 35% after 8 years (Figure 4). In June 2020, AH and PH were caring for 298 patients on maintenance dialysis: 100 were receiving home-based therapies (85 on PD and 15 on home haemodialysis) and 198 were in satellite/in-centre facilities.
The implementation of the new model of care has been associated with the fastest growing rate for home therapies across the State of Victoria [16]. The aim of the project of reaching a 35% prevalent home therapy rate was realised principally through PD and the prevalence rate is the highest for all renal hub services in the state [16].
Discussion
Statement of principal findings
The redesign methodology applied to the ‘Home before Hospital’ project translated to an extremely high patient uptake (>50%) and sustainment (∼35%) of home-based therapies through PD across two collaborating health networks. The project also allowed for an enhanced multidisciplinary approach to support patient decision-making, an improved patient CKD pathway involving the establishment of a nurse lead outreach service and an improved self-efficacy amongst satellite-based haemodialysis patients through a hybrid model.
Strengths and limitations
Like others, a feature and strength of our project was the leadership and engagement of all the stakeholders [17]. As a result, the ownership of the process was ensured, and the teams adopted a shared vision for a patient focussed approach to dialysis care which led to positive outcomes.
Although this project was from a health service perspective extremely successful and a high uptake of home dialysis occurred, a focus on outcomes important to patients and carers (such as quality of life and satisfaction with decisions) has not been formally evaluated. Neither the ANZDATA Registry nor the Victorian Health Department KPIs (see additional data statement) currently includes consistent or specific systematically collected patient reported outcomes. So, as part of the evolution of our program, we are planning in the next iteration to evaluate, monitor and audit patient and carer-reported outcomes referencing the ICHOM standard sets linked to value-based healthcare [18].
In addition, the hybrid component of our care model is still evolving. Although the anecdotal experience appears to be more than promising, there is uncertainty as to the precise benefit for patients and staff. More qualitative and quantitative data would be required.
Interpretation within the context of the wider literature
More than 50% of renal health care providers (nephrologists and renal nurses) believe that independent home-based dialysis therapy is better patient care, yet home dialysis therapy rates world-wide remain low (∼15% [19, 20]). Several factors are potentially relevant in explaining this discrepancy but late diagnosis, late referral to nephrologists, late referral by nephrologists for pre-dialysis education are all implicated. Regardless of the cause, delays in presentation certainly result in ‘sub-optimal’ haemodialysis that starts with an increased likelihood of infection, hospitalisation and death related to central venous catheter use (as arteriovenous fistula not pre-prepared) and lost opportunities for a home-based therapy and its potential associated physical and quality of life benefits.
Nursing staff in many jurisdictions provide outstanding leadership by taking responsibility for the education on the advantages and disadvantages of each dialysis modality: they also inform patients by trying to match the attributes of the therapy to the values and expectations of the patient [9]. Early and repeated quality education was a pivotal principle of our ‘Home before Hospital’ initiative and there was an ongoing willingness to adapt education in response to patient and health professional feedback. The professionalism of that approach may have the effect of encouraging the uptake of a PD home-based therapy. The multidisciplinary approach [21] in our model of care included the communication, confidence and awareness of nephrologists to enable patients to make an informed and supported choice [22].
Other reported benefits of the nurse-led and multidisciplinary education approaches that favourably affect outcomes, include reduced mortality and peritonitis rates [23], reduced use of central venous catheters and less hospitalisations [24] and possible cost savings [25]. One would anticipate that 50% of patients when given an informed choice [6] would choose PD. In our experience the incident rate of PD as modality of choice approached 60% after establishment of the new model of care.
Implications for policy, practice and research
Higher satisfaction rates, increased quality of life, improved survival rates and blood pressure control compared to in-centre haemodialysis have been documented and lead some services to promote home-based dialysis therapies. However, dialysis modality choice is complicated and multi-faceted [26] and include age, physical circumstance and social settings, but most importantly patient preference [27] and a sense of both loss of control and dependence and the overall effect on an individual’s health. Certainly, for home haemodialysis, the limitations on uptake of this therapy include anxiety about self-cannulation, uncertainty about medical support, concern about making errors and perceptions around the burden on caregivers.
Acknowledging that the evidence quality levels remain modest [5], the clinical outcomes for patients treated with PD seem equivalent or perhaps even better than for patients treated with conventional in-centre haemodialysis [4], and therefore, PD provides another acceptable modality for home-based care. For successful home-based dialysis, promoting strategies which encourage a psychosocial profile of self-efficacy and self-esteem (and therefore the required ‘resilience and confidence’ [28]) may also be pivotal and associated with early discontinuation of PD are adverse psychosocial issues. A sense of self-preference is also a key association of longer term survival on the therapy [29].
Although patients anecdotally did extremely well in our study, further qualitative research of sufficient quality [30] specifically addressing key patient and carer outcomes would be required to establish any additional benefits or otherwise of home-based dialysis.
Conclusions
In conclusion, the application of a system-wide approach to a Quality Improvement Process and using established principles and change management processes [12, 13] translated to the implementation of a new sustainable model of care. A key feature of the model (through outreach) was early nurse-led education and support of patients in decision-making through multidisciplinary care.
Supplementary material
Supplementary material is available at International Journal for Quality in Health Care online.
Acknowledgements
The authors wish to thank all renal patients, health care workers and administrative staff across both networks for their support of the project and contribution to the implementation and outcomes.
Funding
Receivedin part from the Victorian State Department of Human Services, Victoria, Australia. https://www2.health.vic.gov.au/.
Contributorship
All authors contributed to the data collection and review and revision of the manuscript.
Ethics and other permissions
As no identifying patient data in the manuscript, data retrieval and collation for publication report did not require approved as a ‘low-risk’ project by local ethics committees.
Data availability statement
The authors confirm that the specific data supporting the findings of this study are available within the article and its supplementary materials. Additional data in the public domain supporting the manuscript are also available at: https://www.anzdata.org.au & https://www.bettersafercare.vic.gov.au/about-us/about-scv/our-clinical-networks/renal-clinical-network.
References