Location is Key for In-House Dialysis Growth For SNFs

As skilled nursing operators look for new paths to take on higher acuity patients, some are turning to in-house dialysis as a way to build back hospital referrals lost during COVID-19.

One wrinkle, however, has proven to be that the rules and regulations around the construction and implementation of these services differ from state-to-state, with some states simply easier and more sensible to set up in than others.

“Clearly, you can’t ignore the fact that it’s an avenue to build census and with folks being much more challenged with census right now I think [many] are looking at new avenues that they may not have had to look at before,” Villa Healthcare CEO Mark Berger told Skilled Nursing News.


Skokie, Ill.-based Villa Healthcare has established in-house dialysis at its facilities in several states across the Midwest. And Berger is hardly the only operator that thinks it’s a good investment at this time.

“Skilled nursing operators out there thinking about what their recovery strategy is going to be and how they are going to reclaim their market share now find themselves with extra real estate and that’s the equation, you have to have the space and the hunger to invest in a new program,” Ray Thivierge, chief strategy officer for SavaSeniorCare, said. “Those two things combined, and COVID-19, served as a catalyst for why I think we’re seeing this preponderance of folks considering these partnerships.”

Rather than sending patients to an off-site dialysis facility, Sava opened its own in-house program to better care for the patients it serves with the goal of reducing hospitalizations and improving clinical outcomes.


With four in-house dialysis programs at its facilities across the U.S., and plans to add several more by the end of next year, Thivierge said Sava has “moved from opportunistic to strategic” in expanding its in-house dialysis program.

Factors for both operators as they look to expand their programs have been location and the pervasiveness of similar specialty programs in the marketplace.

“In newer markets where we open you see a quicker turnaround as far as the increase in census goes,” said Elly Latinik, CEO of RenPro Renal Services, which partners with SNF providers and has dialysis facilities in Illinois, Indiana and Kentucky with pending licenses in several additional states across the country. 

“We’re based out of Chicago, which is a competitive market, but I think the data shows a significant uptick at a quicker pace in newer markets that don’t have as much competition,” he added.

Picking the right state for expansion

Neighboring competition is something that Berger is acutely aware of whenever he looks to add an in-house dialysis program at one of Villa’s facilities.

Expanding in Illinois, for example, is not part of Villa’s current strategy because so many operators in the state have already caught on to the trend. Rather, he looks to expand to states that don’t have as many offerings currently.

“There is no question that in states, where dialysis has never been considered, or minimally considered, as a program that can and should be run out of a skilled nursing facility, has most definitely attracted more referral flow,” Berger said. “We’ve heard from our referral partners that should these programs be there, then they would have an easier time placing those patients.”

He said Villa is looking at states like Minnesota, Wisconsin and Michigan, where operators have been a little slower to catch on.

“We’ve got a few dialysis units in some of the states we service and now we’re expanding that,” Berger explained. “In Michigan right now we’ve got two that are actually in the middle of construction with two more following behind. We’re looking at three sites in the Twin Cities-area that would make sense and in Wisconsin we actually just put the first one in and are looking to open that next month.”

Likewise, Sava plans to open another 10 in-house dialysis programs around the country in its various markets by the end of 2022.

“There’s some states where it is easier to do,” Thivierge said.

North Carolina, for example, has demand but the state’s certificate of need (CON) process makes it a little more challenging, Thivierge added.

“In Georgia there is no CON process, it’s just a matter of getting approval through the state,” he said. “We’re just starting with low hanging fruit first but based on our continued advances in the technology for dialysis, it’s not going to be long before we have several dialysis SNF-based options in every market.”

Thivierge said the technology is so advanced to this point it makes it that practically any building is capable of providing the service.

Still, there are some states where RenPro would like to expand but has chosen not to at this time.

“Some of that is dictated by local municipalities or the state as far as construction requirements go,” Latinik explained. “California, for example, seems to be a large opportunity with a lot of ESRD patients in the state and a lot of SNFs already in place.”

However, the state also has a lot of “hurdles and roadblocks” to overcome when it comes to construction requirements for building in-house dialysis, Latinik said.

He felt those roadblocks were doing a disservice to the patients that live in the state.

“As much as we would love to go into California, our plan is to stay out of it for now until we can find a way to overcome those obstacles,” Latinik said. “There are many states that can still benefit from this that haven’t even been touched yet so I believe there is significant growth ahead.”

Editor’s Note: This article has been corrected with new information about RenPro Renal Services’ size and scope. Skilled Nursing News regrets the error.

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