32 Development of a Home Therapies First Policy
Award category: Best Team Contribution for Service Excellence, Leadership Award through new Ways of
Working and Leadership Award for Safety and Quality
Contact: Royal Hobart Hospital Renal Services
0438 589 811
Within Royal Hobart Hospital’s (RHH) Renal Unit we developed and implemented a philosophy of Home Dialysis
‘First’. This was in response to the increasing literature showing the benefits of self-management in chronic
disease patients and of home dialysis in comparison with in centre (3 x per week) treatment. Individual benefits
include patient empowerment, improved quality of life, decreased travel for treatment, ability to dialyse longer
and more frequently, flexibility to dialyse at a time that suits their lifestyle and improved health outcomes. There
are also secondary benefits such as decreased rates of hospitalisation, ability to return to and maintain a
productive working and family life and significantly lower cost to the health system (Kidney Health Australia.
2012, pp. 11-12). We have also realised since introduction that the phrase Home Dialysis ‘First’ is a misnomer.
Not all patients go home, but some remain independent in the training facility. We are therefore promoting
patient independence in their dialysis treatment. Other patients achieve varying degrees of independence called
assisted care. In 2010 Kidney Health Australia (KHA) undertook a nationwide consumer survey of adult dialysis
patients. This survey showed that 30% of Tasmanian dialysis patients would be willing to dialyse at home.
Our project was to change our model of care to promote independent dialysis and self-management as the
preferred dialysis option, thus aligning with our philosophy. Results from the 2010 KHA survey also enabled
conclusions to be drawn about barriers to home dialysis. Patients are generally comfortable once they are
established on dialysis; this implies that to improve home dialysis rates, patients need to be exposed to home
therapies early to avoid the “status quo” bias against changing to these therapies once established (Kidney Health
Australia, 2011).
In developing our model of care we have combined our Chronic Kidney Disease (CKD) Educator, Home
Haemodialysis (HHD) and Peritoneal Dialysis (PD) teams and placed them in one facility, the Karingal Renal
Education Centre (KREC). Previously they had worked relatively independently of each other. The patient
experience has now changed from a nurse dependent dialysis to independent dialyser who is already reaping the
benefits of their own dialysis. Our patients attend pre dialysis education and information in KREC and are now
exposed to other patients self-managing their own care from the start of their dialysis journey. Pathways were
developed from CKD through to treatment options (Appendix 1) and a framework for home haemodialysis was
developed to assist in defining the level of independence achievable by the individual. This then determines dialysis
location. Buy in was sought and achieved from all members of the renal multidisciplinary team (Dr’s, Nurses,
Allied Health). Patients are now provided with the opportunity to make an informed choice on their treatment
option in consultation with the CKD educator. This aligns with the core principles in the Australian Commission
on Safety and Quality in Health Care (ACSQHC) framework. Namely, to provide care that is consumer centred,
driven by information and organised for safety (ACSQHC. 2013).
Since commencing this project we have doubled our Home Haemodialysis patient numbers from 6 at the start of
the project to 12. Our patients are better educated prior to commencing dialysis and are able to make an
informed choice on the dialysis treatment which works for them. Our patients can also transfer between
home/independent treatment modalities easily as suits their situations. It encourages empowerment and flexibility
and better health outcomes for this patient cohort. The majority of our independent patients dialyse of an
evening thus allowing them to retain their days to live normally and many of these patients are able to continue
to work and enjoy family life.
Patients have a continuum of education and categories of ability and realistically not all can become fully
independent. Patients who are unable to achieve full independence can meet varying degrees of self-management.
These patients are classified as assisted care and can perform aspects of their own treatment as assessed by staff.
This means that instead of them failing to meet certain criteria, they can take pride in what they are able to
achieve.
We have implemented a range of quality improvement initiatives stemming from the new model of care to ensure
that we continue to create a better service for our cohort. These include:
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Commencement of an annual Peritoneal Dialysis (PD) Master Class aimed at providing a continuation of
education and tips for PD patients to keep them healthy and happy on PD. These classes are very person
centric, collaborative and promote home dialysis. They are attended by our medical team and involve
consultation with dieticians and social workers in their planning. Feedback is always gathered from the
patients and families in order to meet their needs and improve what we do. It has been excellent and
attendance is always good (approx. 85%). It provides an opportunity for PD patients to come together to
share experiences and tips, and the feedback has demonstrated how helpful our consumers have found
this to be. One example quoted from feedback comments, “I am not alone”.
Aside from training to undertake their dialysis modality, people who are diagnosed with the beginning
stages of CKD are able to come to KREC and be seen by our CKD educator prior to needing dialysis to
learn about their disease and their treatment options. This enables them to prepare for the upcoming
changes and to learn how to stay as well as they can at home. We find that patient’s feel much more
prepared when they have had the time, along with their family/support systems, to consider what option
best fits their lifestyle. At KREC we have included space for both the renal Social Worker and Dietician
to set up and work. They are both able to see patients here, and easily have involvement with new/home
therapy and independent patients. We find this very useful as do our cohort. Often, pre dialysis patients
are able to not just see the Chronic Kidney Disease Educator, but to be reviewed by the dietician who
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will work with them to keep them as well as they can be at home, prior to commencing dialysis. They
also then have the benefit of the social worker being close by, enabling for early prepare for any extra
support patients will require.
We gained a grant from Kidney Health Australia (KHA) to perform a 12 month trial of patient
education/social classes aimed at CKD and home patients to show them healthy and tasty eating choices
on their required dietary restrictions and easy exercise classes to promote healthy living such as Tai Chi.
The feedback from this was so widely positive that KHA have taken this on board and created the Kidney
Club which is modelled after it.
The development of a brand new initiative in creating ‘Independent dialysis pods’ with 24/7 access in the
Karingal Renal Education Centre has proved to be very beneficial for our patients. The ‘pods’ provide
another dialysis option for independently trained patients. They are given a fob access and dialyse within
the facility independently once they are fully accessed and signed off by staff. It is extremely useful for
those patients who are unable to or don’t wish to perform their dialysis in their own home. Patients who
are deemed safe and competent can attend the facility during or after hours for treatment at their
convenience, around work, school, family and social commitments. This flexibility has provided an
opportunity for those patients who are capable to still become independent instead of being unable due
to logistics. After much work and collaboration they have been set up with all necessary safety measures
(security cameras, door release in case of emergency, checklists and accessible portable telephones) and
are fully operational. Patients continue to have regular meetings with the multidisciplinary team to ensure
that they are well and continuing to be safe.
Our team has created multiple documents and guidelines to support our service such as pamphlets
(appendix 3) training records, troubleshooting and setup manuals for each of the machines as well as
guidelines for assistance with PD dressings. These get constantly updated, and one improvement we have
made because of some patients input (who learn by pictures better than reading), we have added
photographs of set up steps into our dialysis machine manuals.
We have seen a great increase in the family support and involvement for the individual suffering chronic
Kidney disease.
One of our Nephrologists has been able to commence a monthly home therapy clinic at KREC, whereby
patients can come with their families to discuss their progress with their doctor, nursing staff, social
worker and renal dietician. This clinic is both informative for nursing staff to guide us in the care we give
to the individual, but also as an educational opportunity for the patient and their family.
We have also reintroduced an after hours nurse call system to support our independent patients (both
peritoneal and haemo) who dialyse over the weekend, night times or in the evenings.