By waiving the three-day stay requirement for post-acute skilled nursing coverage under Medicare, the federal government has clearly indicated a desire to free up hospital beds by relying more heavily on nursing homes to provide higher-acuity services.
Residents who require routine dialysis treatments are some of the most at-risk patients — and although this population is not the current focal point, if not treated safely inside nursing home walls, they may be endangering themselves and others when traveling in and out of outpatient clinics three days per week.
“Stakeholders right now in the health care industry need to realize that dialysis patients … need to be placed in nursing facilities that have on-site home hemodialysis to reduce the exposure and transmission of the disease that is part and parcel with an outpatient dialysis center transfer,” Dialyze Direct chief compliance officer and general counsel Jonathan Paull told SNN last month, adding that as more dialysis patients are transferred to nursing homes, additional hospital beds will open up — beds very much needed during the pandemic.
The New Jersey-based Dialyze Direct offers in-house dialysis machines and staffing in nine states, and is expanding. So far, the company has seen varying responses to dialysis needs, based on region, in terms of deciding how to discharge these patients.
While some hospitals have quickly rolled out SNF-based hemodialysis strategies, with expedited government-based emergency approvals, other states show hospitals still discharging those with kidney failure back into the community.
A few states are starting to conduct more discharges to nursing homes for dialysis treatment. Paull highlighted the New York Department of Health in working to facilitate faster approvals of dialysis dens in facilities, as well as some Florida independent hospitals and nursing homes developing on-site hemodialysis initiatives.
But these programs are still too far and few between, and more needs to be done involving local departments of health and other state agencies in partnering to safeguard this population by avoiding unnecessary exposure to the virus, Paull said.
Dialyze Direct provides services in 10 states across the country, with hundreds of nursing homes as clients in each state. The company has created a telehealth model for nephrologists and their patients in order to speed up admissions and provide faster care while alleviating exposure and possible transmission of the virus.
Licensed in every state where the company provides care, the virtual program allows providers to review files, create orders, and conduct physician visits, sometimes working in tandem with registered nurses.
In agreement about best dialysis practices occurring inside nursing home walls, the Chicagoland-based Concerto Renal Services is advocating for continuity of care and home dialysis as the smartest way to service these patients.
“It’s always safer for a geriatric patient to dialyze in-house. It’s always less disruptive. There’s always more continuity of care,” Concerto chief operating officer Nosson Factor said.
Concerto Renal Services currently serves more than 500 patients inside nursing homes in the Chicago area. The company also recently took over an outpatient clinic located inside the 267-bed Clinton Healthcare Center in Clinton, Md., part of the Communicare Family of Companies, which has more than 50 patients.
That dialysis clinic was formerly operated by “one of the large dialysis providers … who had effectively given [the SNF] notice on the unit,” Factor told SNN in an April 1 interview.
That transition was effective April 1, and one of the first steps Concerto is taking is to open up new shifts, which will help the operator, he added.
“They had a few extra beds, like seven to 12 extra beds, and the hospital’s been calling them every day saying: We need to offload these dialysis patients, we need open beds in our hospital to handle COVID patients,” he said.
With Concerto opening a third shift and moving the facility to an in-house one, it is now in the process of admitting more patients. And for Kyle Stone, Concerto’s executive vice president and general counsel, this is the key point: These patients would either have had to go to outpatient care or the hospital setting if the unit closed. The COVID-19 outbreak made Concerto potentially reconsider continuing the transition, which had been scheduled before the scale and scope of the disease became clear.
But ultimately, Concerto felt it had a duty to the patients, Stone said.
“We didn’t really have a choice, because we would have been putting a lot of folks in a real tough spot had we not been in a position to ensure we could come in … and begin offering services,” he told SNN on April 1.
Factor also emphasized the importance of keeping dialysis in this setting amid the COVID-19 outbreak, which has spread across the country.
“They’re inside one of the safest places; they’re in a nursing home where every single person who walks in is having their temperature checked, and they’re having to fill out a full attestation saying where they’ve been,” he said.
Concerto is collaborating with their operator partners to identify exact openings for separate dialysis shifts involving COVID-19 patients. In the future, Concerto is expecting a larger infected population, and at that point will begin increasing the capacity of their in-house dialysis program. The company has proactively run through many possible worst-case scenarios in order to be ready for a possible “wartime environment.”
“If I gave you some of the scenarios of what we plan for, it would cause the hair on the back of your neck to stand up,” Factor said. “We’re talking about scenarios where we have no staff, where the entire building is infected, where we have no PPE, and then try to run through those scenarios and say, okay, now what are we doing?”
Even in these dire hypotheticals, Factor advocates for dialyzing and getting creative with alternate PPE options — as well as asking for help from local health departments.
Constant communication between dialysis companies and nursing home partners helps to save lives when nursing home protocol changes based on new information.
“We’ve been in touch with all of our partners proactively and are constantly engaged with them on a daily basis to see what is changing on their end and if there is new policy that they’ve created that they should be sharing with us, to ensure that there’s no lack of communication,” Concerto’s chief executive officer Shimmy Meystel said.
Dialyze Direct and Concerto Renal Services are carefully screening staff and working with nursing homes to ensure they are conducting due diligence on their end. Both companies applauded their hard-working staff for showing up with a positive attitude.
“Those people are the real heroes right now that are going out there on the frontlines and providing care,” Paull said.
Staff are rising to the occasion on the clinical side, Factor added, comparing the current situation to school closings amid major Chicago snowstorms — both external challenges that are part of being in the health care industry.
“Chicago has had some tough winters. Whenever there’s a situation and it’s like, really, really difficult for everyone to get to work, that’s when we have no call-off. That’s when people who are in health care remember why they signed up,” he said.
Maggie Flynn contributed reporting.
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