Nursing Home-Based Hemodialysis: An Opportunity to Broaden SNF Patient Populations & Services
NYS Issues Interim Guidance for COVID-19
On March 21, 2020, the New York State Department of Health (NYSDOH) Division of Nursing Homes and ICF/IID Surveillance issued guidance outlining the process for the emergency provision of home hemodialysis (HHD) services to nursing home residents. The guidelines are associated with NYSDOH’s authority under Gov. Cuomo’s Executive Order 202.1, Continuing Temporary Suspension and Modification of Laws Relating to the Disaster Emergency. This guidance loosens restrictions and grants temporary approval to providers seeking to provide HHD services in the nursing facility.
In 2017, CMS recognized a new modality of dialysis therapy, nursing home hemodialysis, which recognized a nursing home as a resident’s “home,” thereby permitting the development of this service on site. CMS finalized and released the guidance in August 2018. The new guidance confirmed CMS’ recognition of dialysis in a nursing home setting (section 2271A, “Dialysis in Nursing Homes”), and states that Medicare-approved end-stage renal disease (ESRD) facilities can provide dialysis services to skilled nursing facility (SNF) residents in the nursing home with an approved HHD training and support modality.
The new models of service delivery created by the CMS guidance and regulations permit the treatments to be performed within the nursing facility either at the resident’s bedside or in a dedicated space within the nursing home, also known as a “den model.” Prior to the release of the new guidance and regulations, hemodialysis treatments in most states required that hemodialysis patients admitted to or residing in nursing homes be transported to traditional community- or facility-based dialysis units at least three times weekly. For many facilities, particularly those with frail residents with multiple comorbidities, or in cold-weather states, the difficulties are manifold, including the time, cost, personnel requirements and other risks associated with transport to a facility. In many cases, absent an accessible outpatient provider, potential residents remain in an acute care setting to receive required treatment. Numerous benefits associated with nursing facility-based dialysis include, but are not limited to, less disruption and cost versus off-site transport; safer treatment for vent-dependent and fragile residents; and less taxing—although in some settings, more frequent—weekly treatment using dialysis equipment approved for home use.
Recent estimates suggest there are approximately 750,000 ESRD patients in the U.S., with assumptions of up to 10 percent of the broader population residing in nursing homes, based on U.S. Renal Data System and CMS data. Industry analysts suggest that this number will increase significantly based on an observed increase in the 65-and-older population. Given the current and projected growth, this creates numerous competitive advantages for facilities with on-site dialysis capability, including the ability to admit or retain residents who may not otherwise have been appropriate candidates for admission; additional opportunity to coordinate the resident’s care, provide adjunctive therapies and improve treatment goals; increased brand recognition; and hospital referrals related to expansion of the facility’s services and reduced expenses. Additional analysis also suggests that in the Patient-Driven Payment Model environment, this service—and the associated increased acuity profile of the facility’s patient complement—will prove financially beneficial to facilities; as reimbursements are recalibrated for higher acuity residents, they increase both their patient census and care complexity.
Process for Development & Operations
This service, currently active in at least 25 states throughout the nation and with additional programs in development, requires collaborating with a CMS- and state-certified ESRD provider that is licensed to provide HHD and training and support. In states with Certificate of Need (CON) regulations such as New York, the licensure of this program requires submission of a Limited Review CON and survey. According to available information, each state has developed different rules and regulations regarding program establishment. While the dialysis provider bills and retains revenues for the service, the nursing facility benefits from numerous advantages associated with the availability of this program as noted.
In most cases, facilities opting for the den model (which can treat up to four residents per session) identify and renovate dedicated space to meet all regulatory requirements, including architectural, engineering, storage, environmental and other requirements for operating the den. Similar requirements are in place for bedside models, which can accommodate two residents at once, with the exception of those requiring isolation. The contracted approved ESRD provider is responsible for provision of all equipment, supplies and staff. Only ESRD employees may perform HHD activities, and only the ESRD staff RN is permitted to initiate and terminate the dialysis treatment. Numerous other requirements for both the ESRD provider and facility are detailed in the State Operations Manual.
With the focus on expanding covered dialysis service options and easier access to dialysis services, this option is increasingly considered by facilities throughout the nation. For more information, reach out to your BKD Trusted Advisor™ or submit the Contact Us form below.