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As COVID-19 Puts New Focus on Caring in Place, Skilled Nursing Facilities Continue to Explore Dialysis

For skilled nursing facilities, the ability to treat patients in place has far-reaching implications, perhaps most prominently in reducing unnecessary hospitalizations.

Usually that reduction is framed in terms of cost, with penalties for hospitals and SNFs alike if a patient returns to the acute care setting too soon. SNFs that perform well in preventing resident rehospitalizations can earn bonuses, for instance, through the Medicare Value-Based Purchasing (VBP) program.

But even though controversy exists around the effectiveness of that program, there are other benefits. Institutional special needs plans (I-SNPs), a Medicare Advantage program specifically for residents in long-term care facilities, have pointed to the clinical benefits of treating patients in place in any context, but particularly in times of major contagious illness where any interaction can be risky — and hospitals have sometimes been overwhelmed.

And for the residents themselves, treating in place prevents the hassle — and sometimes the trauma — of going to and from the SNF to a new setting. For some operators, dialysis services present an opportunity for SNFs to expand their ability to treat to patients in place — and find their footing in a post-COVID world.

Home hemodialysis in the skilled nursing setting would allow SNFs to avoid some of those rehospitalizations and improve patient outcomes, even before the pandemic, according to Jonathan Paull, chief compliance officer and general counsel at Dialyze Direct.

By offering this service, SNFs can attract new patients who might need it, in turn, improving their census; the operator SavaSeniorCare, for instance, sees adding dialysis services to its SNFs as a way to strengthen census even amid the changes wrought by the pandemic.

But there’s more to it even than that, Paull told SNN in late March.

“There’s another piece to it as well, what COVID has done to change the health care industry forever,” he said. “And that’s created a larger emphasis on on-site, home-based care. It put that into warp speed, because now everyone sees the benefits of what that means for the patients and for the health care industry. With the increased development of telehealth and everything that has come with that with COVID, the result is that you have a bunch of nursing facilities that are looking to move more services on site, in the nursing facility, as opposed to sending patients out for a service and bringing them back.”

With hospitals increasingly sending patients to the home rather than to the SNF setting, dialysis also provides a chance for SNFs to maximize their reimbursement under the Patient-Driven Payment Model (PDPM), which rewards providers for treating higher-acuity patients — a category that includes those who require dialysis, Josh Rothenberg, the chief operating officer and co-founder of Dialyze Direct noted.

This also makes them more vulnerable to illnesses such as COVID-19, as the Centers for Disease Control and Prevention (CDC) found in summer last year. And for dialysis patients who had to go off-site for their treatment, they had an automatic exposure risk with each trip.

“The fact is no matter how the infection control practices they tried to implement within the nursing home, there was this gap, patients that their lives depended on them going outside to a different facility and mingling with other populations and coming back to the nursing home,” Rothenberg pointed out.

Many SNFs and many states, realizing this, have started to take steps to expand their dialysis offerings. Dialyze Direct in March expanded in the state of Kentucky, after participating in a pilot program for SNF home hemodialysis run by the Bluegrass State’s Department of Health.

This was a six-month program for providers interesting in offering home hemodialysis in SNFs, with each dialysis provider allowed to start in one facility of their choice — though Rothenberg noted that he wasn’t aware of any other company participating in the pilot program. At the end of that time, the state surveyed Dialyze Direct and found it met the benchmarks and quality outcomes it was seeking, though Rothenberg and Paull told SNN they did not know which clinical indicators the state was examining.

Over the course of the pilot, Dialyze Direct worked with six patients; it is now working with a “few dozen” facilities in Kentucky, with a presence in about 125 facilities across its entire footprint: Florida, Illinois, Indiana, Kentucky, Maryland, New Jersey, New York, Ohio, Pennsylvania, Tennessee, and Texas. The company is currently expanding to an additional 170 to 180 facilities, Rothenberg said.

Dialyze Direct is planning this expansion in part because of the demand rising throughout several markets, but also because the Centers for Medicare & Medicaid Services (CMS) is focusing on expanding in-house, staff-assisted home dialysis in the nursing home, Rothenberg said.

One of the clearest indicators of that fact lies in an update to the State Operations Manual — “the Bible of nursing home surveyors,” Rothenberg noted — that CMS made a few years ago. It put an emphasis on the need to educate patients; nursing homes have to educate patients on the ability to have home dialysis on-site, and for any patients who want this service, they must either provide it or move the patient to a facility that can provide it.

For Rothenberg, this is one of the biggest signs of CMS’ focus on providing dialysis on-site.

“One nursing home owner … he told me that pre-PDPM, dialysis was another tool to be able to receive more rehab patients,” he told SNN. “Post-PDPM, it became essential in order to strengthen the financial model of the nursing facilities. Post-COVID, it became almost existential for them to have dialysis on-site.”

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