With PDPM’s Higher-Acuity Focus, Skilled Nursing Interest in Dialysis Grows

As skilled nursing providers assess their competencies in dealing with medically complex patients, one area of care could add to their skill set and boost their patient census: dialysis.

Indeed, one SNF — a nursing home owned by Peoria County, Ill. — is expecting to receive an additional $1 million a year through the addition of dialysis services at the Heddington Oaks nursing home, the Journal Star reported. Third-party vendor Dialyze Direct would provide equipment and training, according to the publication.

That arrangement will only materialize if officials approve a three-year contract with Dialyze, the report noted, but if it is, Heddington Oaks would look to boost the number of dialysis patients it serves.

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That $1 million figure could be tempting for operators looking to boost their clinical capabilities in the run-up to the Patient-Driven Payment Model, which will reward providers that can offer more complex services. But operators that want to outfit their facilities with dialysis units will have to carefully tailor their strategies because of significant variances in state regulations, Tim Fields, CEO and co-founder of Ignite Medical Resorts, told Skilled Nursing News.

One of Ignite’s latest new projects, a 144-bed skilled nursing facility in Wisconsin, will feature a dialysis unit in addition to specialized cardiac and stroke care programs. It’s likely to pay off simply because no competitors in the area offer such a service, and there is “a huge need,” Fields said.

But demographics and state licensure will be major factors if a SNF decides to add such a unit or service. Most dialysis units in SNFs are licensed as home dialysis and not outpatient, Fields said, and every government has different rules and regulations around the home dialysis program.

Logistical roadblocks and workarounds

There are different ways SNF can incorporate a dialysis units. One is with daily NxStage dialysis equipment, which can be used at patients’ bedsides or in specialized “dialysis dens” with comparatively little infrastructural investment. The other is three-day dialysis, which requires the installation of water filtration and drainage systems, among other logistical considerations.

Ignite is partnering with Concerto Renal Services, which provides three-day nursing home dialysis, for the Wisconsin unit. Concerto has worked with Ignite before, and has a presence in about 26 SNFs — with six or so facilities in the pipeline, Concerto chief operating officer Nosson Factor told SNN, though that figure can vary at any given time.

Concerto has anywhere from 450 to 500 active patients under its care across Illinois, Wisconsin, and Indiana, with expansion to Maryland, Michigan, and Minnesota in the works. The company opted for the three-day model because of the patient need breakdown, Factor explained: Since most patients receive three-day dialysis, as opposed to five-day or other modalities, that’s the model Concerto opted to follow.

Factor noted that the need for a water room can be a particular logistical roadblock for providers thinking about offering the service. In order to help ease the process, Concerto launched its own water company — Cantata Water Solutions — that specializes in nursing home dialysis installation.

Concerto also offers in-house construction consulting resources to operators to help them through the process. For a six- to eight-chair unit, Factor estimated costs of roughly $25,000 to $75,000 for the build process.

“The actual build costs and logistics are really minimal,” he said. “We’ve never had an operator shy away from us because, ‘Oh, this is too confusing!'”

Opportunity in challenge

Dialyze Direct, on the other hand, uses the NxStage daily model, providing equipment, training, and caregivers within SNFs. The company, which acquired Affiliated Dialysis last year, offers services in Florida, Texas, New Jersey, New York, Ohio, Illinois, and Indiana, with plans to expand further into the Midwest and Mid-Atlantic regions; is the largest provider of home hemodialysis for SNFs, at least according to the company.

Dialyze Direct saw an opportunity in the challenge that dialysis patients present for nursing homes and for hospitals. On the nursing home side, residents who have to travel to a dialysis facility could present a serious readmissions risk, Dialyze Direct COO Josh Rothenberg said.

“If something goes wrong, they go to the hospital, and the hospital penalizes the nursing home, even though the nursing home wasn’t involved,” he said.

And on the hospital front, many patients in need of dialysis and rehabilitation care get stuck in the acute setting for long periods of time because of a shortage of post-acute facilities that will take them in, both Factor and Rothenberg noted.

Once a SNF has decided on a strategy, management will have to analyze local hospital discharge data and talk with local nephrologists to determine if the market has sufficient numbers of patients with end-stage renal disorder (ESRD), Fields said.

“Those conversations will determine if there’s a need and … obviously you don’t want to build a program if there aren’t a lot of patients,” he told SNN.

If there is a need, the payoff for taking them in could be considerable, especially with PDPM taking effect in October. Dialyze Direct, for instance, has begun to see increased interest in its services from nursing homes over “literally the past two months.”

“The reimbursement for rehab is going down, but reimbursement for acuity goes up,” Rothenberg said. “[Nursing homes] have to find ways to bring products into their buildings that will incentivize those patents to come into their buildings.”

And caring for ESRD patients might be a way to do that.

“The analysts have identified that ESRD is a diagnosis that’s going to help drive your rates back up,” Factor said. “With this patient-based model of payment, there’s really not a building that it’s not appropriate for. The only time it’s not appropriate is if the building’s full … it’s kind of if you build it, they will come.”

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