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Funding and Planning: What You Need to Know for Starting or Expanding a Home Hemodialysis Program

Patient Module 1

Authors and Affiliations:

Kirsten Howard, PhD1
Phil A McFarlane, MD, PhD, FRCPC2
Mark R Marshall, MBChB, MPH, FRACP3,4
Debbie O Eastwood, BBus, PG Cert Health Sciences, MSc5
Rachael L Morton, PhD1,6

1The University of Sydney, School of Public Health, Sydney, Australia; 2Division of Nephrology, St Michael’s Hospital, Toronto, Ontario, Canada, and Department of Medicine, University of Toronto, Toronto, Ontario, Canada; 3Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; 4Department of Renal Medicine, Counties Manukau District Health Board, Auckland, New Zealand; 5Department of Medicine and Health of Older People, Waitemata District Health Board, Auckland, New Zealand; 6Nuffield Department of Population Health, Health Economics Research Centre, The University of Oxford, Headington, United Kingdom

Corresponding Author:

Mark R Marshall
PO Box 37968, Parnell 1151
Auckland, New Zealand
Email: mrmarsh@woosh.co.nz, mrmarshall@middlemore.co.nz
Phone: +6421 461766

Conflict of Interest:

See "Global Forum on Hemodialysis in the Home: Sponsorship and Disclosure Statements"

Keywords:

Home hemodialysis; funding; service planning; program start-up; administrative issues; medical director issues

Contents

Abstract
Introduction
Questions to Consider Before Starting a Home HD Program or Writing a Business Case
Writing a Business Case for a Home HD Program
Dealing with RFPs
Conclusion
References
Appendix

 

Abstract

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Planning and funding a home hemodialysis (HD) program requires a well-organized effort and close collaboration between clinicians and administrators. This resource provides guidance on the processes that are involved, including: a thorough situational analysis of the dialysis landscape, emphasizing the opportunity for a home HD program; careful consideration of the clinical and operational characteristics of a proposed home HD program at your institution; the development of a compelling business case, highlighting the clinical and organizational benefits of a home HD program; and careful construction and evaluation of a request for proposal.

Introduction

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Making the correct fiscal case for change is a crucial step in developing a home hemodialysis (HD) program. Smaller programs or pilot projects can often be started and managed within existing hospital HD infrastructure with costs being absorbed into existing funding. Once programs grow to beyond 5-10 patients, there is often requirement for separate and specialized home HD infrastructure and staffing. Figure 1 compares the size of home HD programs between Japan and Australia/New Zealand.1,2 In Japan, most home HD programs are small and located within hospital HD facilities.1 In Australia/New Zealand, home HD programs are larger and, in most cases, enabled by specialized facilities and personnel.2 Expanding a home HD program therefore requires substantial resources, and typically this requires a sound business case for financial investment.

Functionally, a proposal to start or expand a home HD program can be regarded as a 3-step process:

It is vital that the framework and business case are credible and well supported: most providers and payers without experience of home HD programs perceive a high degree of clinical and financial risk in establishing a new home HD program, particularly when they are uncertain about the benefits to patients.3 For those responsible for developing the business case, choosing an overarching framework and deciding on suitable content can be daunting. In order not to be overwhelmed, we recommend that clinicians and administrators work together to accomplish these goals. The importance of this relationship cannot be overemphasized—an individual nephrologist may be able to start a pilot home HD project, but only a team effort will ultimately result in a sustainable and sizeable program.

The medical literature is the best starting point for evidence to support the project. Where it has been evaluated, home HD is less expensive than in-center (facility) HD and is associated with better survival and health-related quality of life.4,5 This has been demonstrated for both conventional short-hour, thrice-weekly HD, as well as frequent and/or extended-hour HD in the home setting.6 In 2010, the National Health Service (NHS) Purchasing and Supply Agency published an economic report of home HD, using assumptions based on the most likely United Kingdom scenario at the time. In that report, home HD dominated satellite HD with a cost saving of approximately £17,000 and a quality-adjusted-life-year (QALY) gain of 0.38 over a 10-year time horizon.7 Home HD also dominated hospital HD, with similar cost saving and QALY gain. The greater cost of satellite and hospital HD was mainly attributable to a greater number of dialysis staff employed and patients’ travel-related costs. Despite the high initial (front-loaded) costs of home HD due to patient setup and training, the payback period (relative to facility HD) is relatively short at approximately 14 months.4, 7-9 When considering these economic evaluations, one must be aware that most are biased against home HD, as these evaluations yield intentionally conservative estimates of cost-effectiveness (eg, no survival benefit is used in base case scenarios, despite multiple observational studies reporting this benefit).10

To navigate this process more easily, the following resources have been developed by a group of clinicians and administrators with first-hand experience in home HD and can be used in the development of business cases and RFPs.

The questions in the next section should be considered in detail before starting or expanding a home HD program, or writing a business case. For each set of questions, we have indicated specific resources that are available to the reader for further information. The clinical and administrative leads of the project should be comfortable that the majority of these questions have been answered to their satisfaction. In most cases, however, there is no “correct” answer. Rather, we encourage readers to consider the options that are available to them, taking into account factors that are unique to their anticipated program structure and size, staffing sources, budget constraints, available equipment, local environment, and cultural practices. In some cases, we have clarified the question with additional considerations that are listed as bullet points.

Questions to Consider Before Starting a Home HD Program or Writing a Business Case

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Clinical Models of Care and Availability of Supporting Services

Q: What mix of home HD therapies will be offered?

Q: Why will these types of treatments be offered?

Q: Is there good support for starting this program at your center?

Q: What is the capacity of facility HD programs?

Stakeholders

It is important to clearly identify internal and external stakeholders in relation to a proposed home HD program. These specific people or groups are those who will be required to support the program, either through mitigating clinical and financial risks or through promoting and/or directly contributing to it.

Q: In your wider dialysis program, have you assessed patients’ levels of awareness and interest in home HD?

Q: In your local region, are there initiatives or policies directed to increase the proportion of patients on home HD?

Q: What information is needed to approach the department of human services, government, or ministry payer for increased reimbursement and initial capital expenditure to fund a home HD program?

Q: What factors will encourage administrators and clinical staff to become supportive and engaged?

Q: How will home HD candidates be identified and made known to the home program?

Q: How will the home HD program integrate with local dialysis services?

Q: For patients identified as candidates for home HD, what resources are required to ensure that such patients can have a smooth and optimal dialysis start?

Budget

A key component to a successful launch of a new home HD program is to ensure that the program is financially sustainable. It is accepted that home HD is a cost-effective alternative to conventional facility HD and an attractive option from a health system and societal perspective. However, these “global” cost savings may not help a local program that has day-to-day costs that are more than their incoming funding. For example, reductions in the costs of hospital admissions and medications may be attractive to the payer (eg, in the case of Ontario, Canada, the Provincial Ministry of Health), but these costs are usually not borne by the dialysis program, so they do not contribute to financial sustainability at the program level.

An important consideration is modality mix, in terms of extended-hours or frequent HD. Longer treatments have very low marginal costs per dialysis hour, as the only additional costs are for extra utilities (ie, power and water) and dialysate. More frequent treatments have higher marginal costs per dialysis hour due to the need for new connectology, tubing sets, and dialysis membranes.

Q: How does the dialysis equipment affect these costs?

Q: How is home HD funded in your local region (ie, paid by modality type, per week, or per treatment)?

Q: What are the anticipated costs relative to the funding level?

Q: What are the potential resource impacts on other hospital programs?

Q: What should be done if the home HD program is running (or anticipated to run) a budgetary negative variance (ie, costs are higher than incoming funding)?

Home HD Training and Physical / Organizational Infrastructure

Q: Where will home HD training be performed, and where will the home HD hub be located?

Q: When will training occur?

Q: Where will capital funds be obtained to complete necessary renovations and/or construction to create the required training and clinical space? What is the budget for such construction?

Capital Equipment

Capital equipment is one cost category where home HD is more expensive than facility HD. For facilities, an item such as a HD machine is typically shared among 6 patients, and a water treatment plant would supply water to all of the patients in a dialysis unit. In the home setting, each patient needs his or her own HD machine and water treatment equipment. In addition, the patient’s home may require moderate renovations to provide sufficient water, drainage, and electrical service to the room where the treatments will be performed (see “Infrastructure, Water, and Machines in the Home”). Additional items may be required for patient purchase, such as scales and blood pressure machines (see “Patient Specific Costs”).

The major capital purchases for the home will include the HD machine and the water treatment system.

Q: How will this equipment be purchased or provided?

Q: How many HD and water treatment machines are needed for the program?

Additional Resources
  • Costs of starting and maintaining a home HD program:
    • Komenda P, Copland M, Makwana J, Djurdjev O, Sood MM, Levin A. The cost of starting and maintaining a large home hemodialysis program. Kidney Int. 2010; 77:1039‒1045.12
  • Example of payer support for home HD:
    • Nissenson AR, Moran J. A large dialysis provider committed to home modalities. Am J Kidney Dis. 2012; 59:739; author reply 739‒740.13
  • Example of a centralized home HD training model:
    • Honkanen EO, Rauta VM. What happened in Finland to increase home hemodialysis? Hemodial Int. 2008; 12 Suppl 1:S11‒15.14
  • Example of home HD training in a Japanese HD facility:
    • Tomita K. Practice of home hemodialysis in dialysis clinic. Contrib Nephrol. 2012; 177:143‒150.15
  • Home training support for patients in remote areas:
    • Zacharias J, Komenda P, Olson J, Bourne A, Franklin D, Bernstein K. Home hemodialysis in the remote Canadian north: treatment in Manitoba fly-in communities. Semin Dial. 2011; 24:653‒657.16

Staffing

Q: How will nursing and other dialysis staff be hired?

Q: How will technical support for home HD machines be provided?

Q: What types of after-hours support will be provided to your home HD patients?

Q: Will a nurse and/or technician home visiting service be provided?

Q: How many staff and transportation vehicles are needed for home visits?

Q: How will new home HD staff be trained and developed? (See “Workforce Development and Models of Care”)

Additional Resources
  • Example of building a home HD unit from an existing PD unit:
    • Borg DL, Keller JA, Faber MD. Adding home hemodialysis (HDD) to a peritoneal dialysis (PD) program. Nephrol Nurs J. 2007; 34:138.17
  • Examples of resources required to start a new home HD program:
    • Agar JW. Home hemodialysis in Australia and New Zealand: practical problems and solutions. Hemodial Int. 2008; 12 Suppl 1:S26‒32.18
    • Moran J, Kraus M. Starting a home hemodialysis program. Semin Dial. 2007; 20:35‒39.19

HD Machine Maintenance and Delivery of Supplies

Q: What mechanism will be used for stock-take and delivery of supplies to patients’ homes?

Q: Who will be in charge of ordering supplies?

Q: In the case of using the dialysis vendor’s systems, how will this be incorporated into the patient contract?

Q: Waste management and disposal in the community: are there any local restrictions?

Q: What are the arrangements for initial home HD power and water setup in patients’ homes?

Q: Who will pay for the home utilities including heating, power, and water?

Q: How will maintenance of the dialysis equipment be performed?

Q: Who will provide periodic water monitoring, and what are the costs of this ongoing monitoring?

Q: How will maintenance of the water system be performed?

Patient-Specific Costs

In a home HD program, some cost categories are moved from the program to the patient, which can potentially offset the benefits of home HD for the patient through avoiding other costs related to, for example, transport and parking. For example, home HD is associated with an increased demand for power and water, which are often paid for by the patient. Consideration should be given to the costs that may be borne by the patient and how these would be handled if the patient did not have sufficient resources to pay for them. It is important to be clear from the start who bears the financial responsibility for what costs, if necessary, by legal agreement.

Q: Who will pay for any renovations to the home required for the patient to initiate home HD?

Q: Many rented or leased homes require that any dialysis-related alterations made to the home will be removed and the home restored to predialysis condition when the patient moves.

Q: If the program is covering costs related to home renovations, is there any limit to the number of times a patient can change residence?

Q: Who will pay for assorted single-time purchases such as scales, blood pressure machines, tables to hold equipment and supplies, recliner chairs, and leak detectors, if appropriate?

Q: How will the increased cost of power and water be handled?

Additional Resources

Published examples of the costs of a home HD program:

  • McFarlane P, Komenda P. Economic considerations in frequent home hemodialysis. Semin Dial. 2011; 24:678‒683.20
  • Komenda P, Copland M, Makwana J, Djurdjev O, Sood MM, Levin A. The cost of starting and maintaining a large home hemodialysis program. Kidney Int. 2010; 77:1039‒1045.12

Writing a Business Case for a Home HD Program

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The next step in establishing a home HD program is to secure funding for capital and operational expenses and initiate the procurement of the necessary goods and services. To do so, most private and public payers require a business case: a document designed to justify expenditure of money and effort in order to make a decision on funding.

A compelling business case is a well-structured and logical document. It captures the expected clinical benefits of developing a viable home HD program for the patient, identifies the required resources, defines models of care, and determines the relative priority of the program in relation to competing initiatives.21 For the payer, the business case helps reassure that:

  1. The program is a high-value opportunity with measurable and accountable clinical benefits
  2. The nephrology service can deliver the purported benefits
  3. Due consideration has been given to complex interdependencies with other services such as surgery, radiology, and information technology; and
  4. Quality, patient safety, and incident management aspects of the program have been considered and incorporated

Occasionally, there will be payer templates available to use in preparing business cases; these should be followed strictly. More often, business cases are formal but unscripted, and should contain the following key elements (Table 1):

Glossary

Executive Briefing or Summary

Introduction or Background

Service Objectives and Critical Success Factors

 Approach or Methodology

Overall Scenario Analysis or Justification

Linkages and Stakeholder Summary

Implementation

Risks and Mitigation

Dealing with RFPs

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When a large contract or capital proposal is being offered to vendors, most private and public payers require that a request for proposal (RFP) or request for tender (RFT) process be followed. The RFP process is usually highly scripted, with many rules and regulations. In the case of publicly funded systems, the RFP process may be codified in law. In all cases, the RFP process must strictly adhere to the local rules and guidelines to protect the program from a variety of liabilities. As a result, it is in the interest of those starting a new home HD program to become familiar with their local RFP process.
Before embarking on an RFP for home HD equipment and service, it is important to become familiar with the strengths and weaknesses of various vendors. Once an RFP is open for tender, it usually cannot be altered. The RFP process is not the time to learn about what vendors are able to offer—this should be done before construction of the RFP. The RFP is best written by a multidisciplinary home HD program team, including an experienced dialysis nurse and technician. This team will research the following topics and consider the costs, where applicable.

The HD Machine

The Water Treatment Equipment

Information Technology

Full-Service Provision Options

Once the home HD program team has become familiar with the offerings of the various vendors active in their region, the RFP can then be constructed. It is crucial that the program team be clear about which features and services they expect from the vendor and their equipment. The program team should construct a “wish list” of desired features and rank them in terms of importance. Some features are critical and a vendor will be eliminated if they cannot deliver this feature. Others will be desirable, but will not necessarily be deal breakers if they are absent. Proper construction of the “wish list” is important because most RFP processes require not only a list of desired features, but the weighting applied to each of these features. The vendors will be asked to submit a list of services and equipment that will be provided, and a list of charges. The program team should understand its budgetary limitations before constructing the RFP and consider what weight will be applied to the budget component of the RFP.

It is extremely important that the RFP be constructed properly. The RFP should be written in a manner that ensures that the program team is able to select a vendor that will meet not only all of their needs but also the program’s budgetary requirements as well. A vague and poorly written RFP may lead to selection of an inappropriate vendor.

Because the RFP process is highly regulated, the program team involved in creating the RFP should understand the local rules governing that process. For example, once the RFP is completed and open for vendors to review, changes to the contents of the RFP are usually not permitted. Interaction between the vendors and the team is usually highly restricted. For example, the program team may not be allowed to meet or communicate with members of a vendor company outside of the channels of communication that are part of the RFP process. Team members participating in developing the RFP should also be prepared to give a detailed list of potential conflicts of interest, based on previous involvement with the each vendor.

Conclusion

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Planning and funding a home HD program requires a well-organized effort and close collaboration between clinicians and managers. Up to a year should be allocated for the following:

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References

  1. Data on file. Baxter Healthcare Japan Ltd. 2014.
  2. ANZDATA Registry. Summary of Australia and New Zealand Dialysis and Transplantation 2012. Adelaide, Australia. Available at: http://www.anzdata.org.au/anzdata/AnzdataReport/36thReport/2012_Summary_v1.pdf. Accessed September 4, 2014.
  3. Tong A, Palmer S, Manns B, et al. Clinician beliefs and attitudes about home haemodialysis: a multinational interview study. BMJ Open. 2012; 2:e002146.
  4. Mowatt G, Vale L, Perez J, et al. Systematic review of the effectiveness and cost-effectiveness, and economic evaluation, of home versus hospital or satellite unit haemodialysis for people with end-stage renal failure. Health Technol Assess. 2003; 7:1–174.
  5. Dale PL, Hutton J, Elgazzar H. Utility of health states in chronic kidney disease: a structured review of the literature. Curr Med Res Opin. 2008; 24:193–206.
  6. Walker R, Marshall M, Morton RL, McFarlane P, Howard K. The cost effectiveness of contemporary home haemodialysis modalities compared to facility haemodialysis: a systematic review of full economic evaluations. Nephrology (Carlton). 2014; 19:459–470.
  7. Ananthapavan J, Lowin J, Bloomfield E. Economic report: home haemodialysis (CEP10063). London, UK: NHS Purchasing and Supply Agency; 2010. Available at: http://nhscep.useconnect.co.uk/CEPProducts/Catalogue.aspx?ReportType=Economic+report. Accessed June 10, 2014.
  8. Mackenzie P, Mactier RA. Home haemodialysis in the 1990s. Nephrol Dial Transplant. 1998; 13:1944–1948.
  9. Delano BG, Feinroth MV, Reinroth M, Friedman EA. Home and medical center hemodialysis. Dollar comparison and payback period. JAMA. 1982; 246:230–232.
  10. Marshall MR, Hawley CM, Kerr PG, et al. Home hemodialysis and mortality risk in Australian and New Zealand populations. Am J Kidney Dis. 2011; 58:782–793.
  11. Mendelssohn DC, Curtin B, Yeates K, et al. Suboptimal initiation of dialysis with and without early referral to a nephrologist. Nephrol Dial Transplant. 2011; 26:2959–2956.
  12. Komenda P, Copland M, Makwana J, et al. The cost of starting and maintaining a large home hemodialysis program. Kidney Int. 2010; 77:1039–1045.
  13. Nissenson AR, Moran J. A large dialysis provider committed to home modalities. Am J Kidney Dis. 2012; 59:739; author reply 739–740.
  14. Honkanen EO, Rauta VM. What happened in Finland to increase home hemodialysis? Hemodial Int. 2008; 12 Suppl 1:S11–15.
  15. Tomita K. Practice of home hemodialysis in dialysis clinic. Contrib Nephrol. 2012;177:143–150.
  16. Zacharias J, Komenda P, Olson J, et al. Home hemodialysis in the remote Canadian north: treatment in Manitoba fly-in communities. Semin Dial. 2011; 24:653–657.
  17. Borg DL, Keller JA, Faber MD. Adding home hemodialysis (HDD) to a peritoneal dialysis (PD) program. Nephrol Nurs J. 2007; 34:138.
  18. Agar JW. Home hemodialysis in Australia and New Zealand: practical problems and solutions. Hemodial Int. 2008; 12 Suppl 1:S26–32.
  19. Moran J, Kraus M. Starting a home hemodialysis program. Semin Dial. 2007;20:35–39.
  20. McFarlane P, Komenda P. Economic considerations in frequent home hemodialysis. Semin Dial. 2011; 24:678–683.
  21. Adams A. ABC MedTech Case. In: Sheen R, Gallo A, eds. HBR Guide to Building Your Business Case Ebook + Tools. Boston: Harvard Business Review Press; 2012; 1–23.
  22. Technology Appraisal Guidance No. 48; Guidance on home compared with hospital haemodialysis for patients with end-stage renal failure. London: National Institute for Health and Care Excellence; 2005.
  23. Masterson R. The advantages and disadvantages of home hemodialysis. Hemodial Int. 2008; 12 Suppl 1:S16–20.
  24. Christensen AJ, Smith TW, Turner CW, Holman JM Jr, Gregory MC. Type of hemodialysis and preference for behavioral involvement: interactive effects on adherence in end-stage renal disease. Health Psychol. 1990; 9:225–236.
  25. Polaschek N. Haemodialysing at home: the client experience of self-treatment. EDTNA ERCA J. 2005; 31:27–30.
  26. Polaschek N. Client attitudes towards home dialysis therapy. J Ren Care. 2007; 33:20–24.
  27. Schorr M, Manns BJ, Culleton B, et al. The effect of nocturnal and conventional hemodialysis on markers of nutritional status: results from a randomized trial. J Ren Nutr. 2011; 21:271–276.
  28. Kraus M, Burkart J, Hegeman R, et al. A comparison of center-based vs. home-based daily hemodialysis for patients with end-stage renal disease. Hemodial Int. 2007; 11:468–477.
  29. Levy J. Home dialysis can improve quality of life. Practitioner. 2007; 251:8,10–12,14,15.
  30. Blagg CR, Kjellstrand CM, Ting GO, Young BA. Comparison of survival between short-daily hemodialysis and conventional hemodialysis using the standardized mortality ratio. Hemodial Int. 2006; 10:371–374.
  31. Kjellstrand CM, Buoncristiani U, Ting G, et al. Short daily haemodialysis: survival in 415 patients treated for 1006 patient-years. Nephrol Dial Transplant. 2008; 23:3283–3289.
  32. Nesrallah GE, Lindsay RM, Cuerden MS, et al. Intensive hemodialysis associates with improved survival compared with conventional hemodialysis. J Am Soc Nephrol. 2012; 23:696–705.
  33. Johansen KL, Zhang R, Huang Y, et al. Survival and hospitalization among patients using nocturnal and short daily compared to conventional hemodialysis: a USRDS study. Kidney Int. 2009; 76:984–990.
  34. Culleton BF, Walsh M, Klarenbach SW, et al. Effect of frequent nocturnal hemodialysis vs conventional hemodialysis on left ventricular mass and quality of life: a randomized controlled trial. JAMA. 2007; 298:1291–1299.
  35. FHN Trial Group, Chertow GM, Levin NW, et al. In-center hemodialysis six times per week versus three times per week. N Engl J Med. 2010; 363:2287–2300.
  36. Nesrallah G, Suri R, Moist L, Kortas C, Lindsay RM. Volume control and blood pressure management in patients undergoing quotidian hemodialysis. Am J Kidney Dis. 2003; 42:13–17.
  37. Mucsi I, Hercz G, Uldall R, et al. Control of serum phosphate without any phosphate binders in patients treated with nocturnal hemodialysis. Kidney Int. 1998; 53:1399–1404.
  38. Hladunewich MA, Hou S, Odutayo A, et al. Intensive hemodialysis associates with improved pregnancy outcomes: a Canadian and United States cohort comparison. J Am Soc Nephrol. 2014; 25:1103–1109.
  39. Barua M, Hladunewich M, Keunen J, et al. Successful pregnancies on nocturnal home hemodialysis. Clin J Am Soc Nephrol. 2008; 3:392–396.
  40. Rocco MV, Lockridge RS Jr, Beck GJ, et al. The effects of frequent nocturnal home hemodialysis: the Frequent Hemodialysis Network Nocturnal Trial. Kidney Int. 2011; 80:1080–1091.
  41. Komenda P, Gavaghan MB, Garfield SS, Poret AW, Sood MM. An economic assessment model for in-center, conventional home, and more frequent home hemodialysis. Kidney Int. 2012; 81:307–313.

Appendix

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Glossary
The following terms and definitions are specific to dialysis, as discussed in this article.

Direct costs

Costs directly attributable to the dialysis procedure, including capital costs and the portion of operating costs specific to the provision of dialysis. This will include the cost of dialysis machinery, consumables, and salaries for dialysis staff

Dominant (health economics)

The intervention costs less and is at least as effective as the alternative

Indirect costs

Costs are not directly attributable to the dialysis procedure, and include costs for overhead, management, insurance, taxes, maintenance, and accommodation

Payer

The organization that pays for dialysis-related hospital or medical bills instead of the patient. This is often a government-contracted intermediary, an insurance carrier, or managed-care organization

Provider

Hospitals, physician groups, commercial entities, or other healthcare agencies such as a large dialysis organization that are contracted for the direct delivery of dialysis to the patient

Vendor

A commercial entity that is engaged by providers in the normal course of business. This is often a manufacturer of dialysis machinery or a reseller


Checklist for Costs Related to Infrastructure for HD in the Home

‡

Patient Training and Assessment

  • For example, training in the dialysis clinic, hospital, or patient’s home
  • Staff visits to the home and associated travel costs

‡

The Patient Dwelling

  • Housing improvements/construction/retrofitting/repairs needed for dialysis-related alterations. Written instructions should be available concerning who is responsible for paying for dwelling alterations in connection with dialysis installation, and how often requirements are to be reassessed
    • Rental properties may have restrictions on what can be modified and whether the dwelling will need to return to its original condition if the patient relocates
  • Extra dialysis outlets (eg, weekend cottage)
  • The patient may choose to relocate at some point while undergoing home HD. What costs are required to restore home/rental unit to predialysis state? The economic consequences and responsibilities of this action should be outlined and planned for in all legal agreements
  • Tax considerations. Some dwelling modifications may be tax deductible for patients

‡

HD Machine

  • Rent or purchase
  • Repairs and maintenance
  • Replacement

‡

Furnishing and Equipment

  • Chair
  • Scales
  • Cupboard
  • Lighting
  • Refrigerator
  • Leak detectors
  • Blood pressure equipment

‡

Water Supply

  • Installation and required modifications in the home
  • Water purification
  • Water consumption
    • Public water rates can be quite high due to local water shortages or environmental considerations
    • Consider reduction in flow rates to 200 mL/min for long dialysis regimens (eg, nocturnal HD)
    • Water supplied by dialysis vendors may be expensive
  • Maintenance

‡

Water Quality Testing

  • Cost of testing (eg, provided by the nephrology service or outsourced to a private company)
  • Frequency
  • Staff required to perform testing

‡

Water Disposal

  • Local requirements

‡

Plumbing (see Water Supply)

‡

Electricity Supply

  • Installation and required modifications in the home
  • Safety considerations (eg, additional grounding of electrical wires)
  • Power surge protector
  • Backup supply (eg, generator)
  • Electricity consumption
  • Maintenance

‡

Waste Disposal

  • Requirement for extra waste bins
  • Local restrictions and special disposal

‡

Communications

  • Telephone
  • Internet

‡

Disposables

  • Filters (single use or reusable)
  • Dialysis lines
  • Needles
  • Dressings and plaster
  • Disinfectants
  • Fluids
  • Delivery charges

‡

Medicines

  • Drugs associated with dialysis process (eg, erythropoietin, intravenous iron)
  • Fluids (sodium chloride)

‡

Assistance

  • Most dialysis programs expect the dialysis to be performed by the patient, with the possible assistance of an unpaid family member. If paid assistance in the home is considered, the cost of this also needs to be calculated in overall costs
  • Respite care for patient
 
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