Dr. Michael Kraus: Welcome, everyone, to this episode of Field Notes. I'm Dr. Michael Kraus, the Associate Chief Medical Officer at Fresenius Kidney Care and your host for this discussion today. Here we interview the experts, researchers, physicians and caregivers who bring experience, compassion and insight into the work we do every day. 

At Fresenius Medical Care, we are committed to giving our patients the best quality of life possible. That is why we are committed to increasing the number of patients receiving home dialysis, which provides them with a greater sense of control, confidence and independence. The fact is home dialysis is the best option to treat kidney failure prior to transplantation or even if a transplant is not feasible. We are wholly committed to growing home therapies and growing a culture of home dialysis education in our centers.

Home dialysis offers control and the ability to easily increase frequency and duration of therapy to meet a patient's clinical needs. In order to grow home therapies, we need to explore the pathway of moving patients from the in-center to home, as well. We believe that home is a great clinical improvement to many of our patients. Today, we have two experts with us to discuss what we can do to increase the number of patients transitioning from in-center to home dialysis. Scott Ochs, Vice President of Home Therapies at Fresenius Kidney Care, and Dr. Alpana Pasricha of the Nephrology Specialists of Tulsa, Oklahoma.

Dr. Alpana Pasricha: Thank you.

Scott Ochs: Thank you. Great to be here.

Dr. Michael Kraus: Now, Scott, let's talk with you. You've always been involved in home from almost the very beginning of your career. Why is home therapies important?

Scott Ochs: Primary thing that I see is that it allows patients to take control of their lives back. You know, when patients have to go to an in-center clinic for three days a week and treat for ideally 4 hours each time, that's a lot of time out of their day and they lose a lot of control of their life.

So going home really helps empower the patient. You know, it's easier for them to travel, to do vacations, the things that they like, the things that they probably had to give up if they were doing it in-center dialysis, hang out with family and friends. It's just less of a burden and there's lots of health benefits, as well. I'll let Dr. Pasricha to cover those, but those are numerous, as well.

Dr. Michael Kraus: And Dr. Pasricha, let’s hear from the physician standpoint. Why is home therapy such a critical component to the care you provide?

Dr. Alpana Pasricha: I believe that home therapies should be the dialysis modality by default. You know, when I have a patient that's approaching end stage and they're feeling anxious about the process, I tell them to consider that this is just going to be a change in their lifestyle and that I will work with them closely till they feel comfortable, confident and in control until it becomes a part of their daily routine.

I think that this transition and the ongoing success is a critical part of my nephrology practice.

Dr. Michael Kraus: Do you have a personal story, a patient story or anecdote that you can tell us about a successful home journey?

Dr. Alpana Pasricha: So, this patient first came to see me in the office, and I found out that he was already an established patient on in-center hemodialysis. Well, he explained to me that he had heard about peritoneal dialysis and had been asking for two years, but he was told that he was not a candidate. His clinic manager had suggested him to come and see me.

It was clear that his BMI was very high. However, I've never considered that a contraindication. So, I took him on PD, and he did amazing. Well, it wasn't just that. A few years passed and he had a cardiac event, went into pulmonary edema and had heart surgery and a prolonged hospital stay. At that point, the nephrologist and that hospital again told him that he would never be able to go back on PD and scheduled his PD catheter to be removed.

The patient refused and had the nephrologist clear with me. Well, I told him to leave the catheter in and that I would figure it out. After he recovered and came back to me, he had lost residual and I took him back on PD. We managed to play around with his regimen and fast, and he spent another nine months on PD. He passed away, later. His wife, especially, came back to thank me for the quality time that they were able to spend together.

Dr. Michael Kraus: Volume issues, but you're able to control it with peritoneal dialysis alone and home, providing that great place for the family. Scott, is there a patient story you can think of? 

Scott Ochs: Oh, there's so many great ones. But the first one that comes to mind, Dr. Kraus is a patient…I'm just going to call him John. That's not his name, but just to give this patient a name. So, John was an in-center patient, and he was very noncompliant. He had a hard time showing up for treatment. He was aggressive with the staff. And, you know, for some reason, there were many staff members whom he just wouldn't talk to. And not only would he not talk to them, he wouldn't come to treatment if he thought they were at work. 

And so, I decided, you know, as a Director of Operations, I'm going to sit down with this guy and I'm going to help him out. I'm going to figure out what's bugging him and we're going to, quote unquote, fix this guy, right? So, I sat down to speak with him, and I immediately got on the list of people he didn't like. And so, years ago, we would have said, well, this is somebody who is not a great patient for home, right? He needs to somehow earn his way home. He needs to show up for X amount of treatments. And the home therapies team said, hey, why don't why don't we give John a shot at home? It looks like it's control he's after and it looks like he has a hard time in this environment. Most definitely had some psychological issues, and so we gave John a try at home hemo. And he's been there… it's been at least five years, and he is now a poster child of home hemo for what we used to think of, you know, the noncompliant patient being a bad candidate.

He was a great one and it's worked out so well for him. So he's just somebody that is doing phenomenally, he's living his life well. He's not disrupted by, you know, all the noises and the commotion of in-center and just doing phenomenal.

Dr. Michael Kraus: That's great. I think we all agree that home dialysis, both peritoneal dialysis and home hemo is better for many of our patients and improves their quality of life and hopefully even their quanity of life. Scott, why is in-center to home so important?

Scott Ochs: In-center to home is important for a few reasons. You know, I think first about the patient’s home, home, we… and we being the caregivers in the clinic that work for Fresenius: the extender for the physician, the physician themselves, we've made assumptions about folks sometimes from the moment we meet them that this person should go in-center or this person is a great home candidate because of A, B or C.

And so, when we think about the in-center patient and approaching them with a mindset of every patient can go home until they either fail or they fully understand what the opportunities with home balances look like for them. And they say no thanks, right, with an empowered decision. And so, it's a different way of approaching patients. And I can't tell you how many times we've seen patients not just choose home but be successful at home when we had originally assumed, maybe even judged them not to be good candidates with, you know, John being that great example. That's happened countless times.

So, it's the right thing to do, I think, Dr. Kraus. That's why it's important, because it allows everybody, you know, to make that empowered decision, and I think you and I and Dr. Pasricha would all choose a home modality if we had to do dialysis. And that's because we're informed. And so, our patients should be informed as well.

Dr. Michael Kraus: And this in-center to home is also important as we grow, right? I can't grow home dialysis without moving people to home. Where are all our patients? Well, we know that 85 to 86% of them are in-center. So, let's begin to get those patients moved to provide them better care and to grow home and provide better care for them.

While we're on that, Dr. Pasricha, you do that in Tulsa. In fact, your in-center transitions in the Tulsa unit are among the highest in Fresenius Kidney care today, over 1.8% of your patients are transitioning monthly now. And how did you get there? Especially, let's focus on the in-center to home. What changed? What's the secret source of moving patients from in-center to home?

Dr. Alpana Pasricha: My thoughts actually echo Scott so closely. So, I believe this is all about mindset. Our home penetration is close to about 25% and we have 250 home patients. Every time I walk into the dialysis clinic for rounds, and I have done this for years, I get this same knowing feeling in me. That is, what are all these patients doing here? This is not where they belong. 

In my conversations with them, I'm not just addressing the Kt/V, the labs or the volume status. There is an acute awareness in my mind to bring out one other reason why and how home therapies would be a better way of doing this. And that's how you change the culture.

Dr. Michael Kraus: It takes the entire team. While we're on that, Scott, that means to me the physician culture has got to change. Physicians have to be like Dr. Pasricha and walk in, say it's time to get home. From the Fresenius Medical Care perspective, what are we doing to support the physicians and the providers and educating them about home therapies?

Scott Ochs: Fundamentally, it's people, right? So, utilizing our folks like our directors of market development to work with physicians, our NxStage representatives to make sure that they're in physician offices and showing them the data, the benefits, the tangible, as well as the intangible benefits of home. And of course, our Kidney Care Advocates whose job is to work with physicians and their patients before they even get to dialysis, before they even need it to ensure that our patients understand what options they have. And of course, that means we've got to be working hand-in-glove with the doctors first.

Dr. Michael Kraus: You've said it, and I think we've all said, you know, home is everybody's responsibility and certainly I'm going to plug it. Things like this Field Notes, things like Case-Based Learnings that are available in the Medical Office Newsroom, are also very good tools for our physicians. Dr. Pasricha, how about the other members of the IDT? How do you get your in-center nurses and your PCTs and everybody or who do you involve in that conversation?

Dr. Alpana Pasricha: So, you know, as a physician, I see my patients once a month, and I think that's common practice. It's our mid-levels that are seeing them once a week. And I think they often have a greater rapport with the patients. I believe that I’d like to educate and involve my mid-levels to be more proactive on this topic. 

The next level is, of course, the nursing staff, the techs. They are seeing the patients every treatment. So, the more aware and educated they are, they can have a greater impact on the patient’s decision. They see them, they have more conversations with them. That that's how I like to approach that. 

Dr. Michael Kraus: I think that's exactly right. As a physician, you have to make sure that your staff understand exactly why you believe in home and get them to say the same message. Scott, you know, we didn't talk about patients to patients. Peer mentoring is so important in almost every aspect of practices and certainly home dialysis is no different. Can you briefly tell me about the role of patient advocates and the importance of peer mentoring?

Scott Ochs: Even our best KCAs can provide great education, but man, when you hear from someone who's been there, that just carries a weight that you can't ignore. You know, a patient advocate has the real ability to empathize, to understand and to relate. They've been there. So, it's really transformational to have patients be able to hear from other patients who've done it.

Dr. Michael Kraus: Seeing somebody looks like you, this gives you that assurance of safety that everybody is worried about as we talk about home. While we're talking about building up that assurance of safety in education, we also have a lot of Transitional Care Units and things like Experience the Difference. Scott, can you briefly tell us what roles those play? 

Scott Ochs: Transitional Care Units, or TCUs, and Experience the Difference are a couple of really good tactics I've used to grow home therapies. And the TCUs really helped provide a soft landing for patients where they can experience each modality in some fashion. It's sometimes stylized, both on a 2008K@home machine as well as a NxStage machine. So, they can understand the difference, they can see the difference, they can touch, they can understand and really get education from nurses whose… that's their job.

It's not to just provide them dialysis but educate them on all modalities and their options. They can look at a PD cycler, they can see demonstrations of what peritoneal dialysis looks like. And so, it really is a foundational experience. And we see that patients who go through TCUs, about 35% of them end up choosing home, whereas about 18% of our patients now just new to dialysis are choosing home, so, it's providing a lot of value.

And then Experience the Difference is quite similar. So, for the existing in-center patient, we allow them to treat on a NxStage machine for a couple of weeks and do just that, experience the difference. So, get more frequent dialysis. They feel better. They see how simple dialysis can be, right? It's not this big machine with so many buttons and confusing screens to go through.

It's much simpler. And so, they say, well, you know what? I can do this. And so, for those patients that have experienced dialysis, this is quite eye opening for them. And we see a very high percentage of patients who do Experience the Difference choose home, as well.

Dr. Michael Kraus: Excellent and Dr. Pasricha, as we think about quality and growth, you know, all of those things always work when you set goals and you follow and you get measurable goals and you report them. How do you do this with growing your home? What do you do in your unit?

Dr. Alpana Pasricha: I found in my earlier years that you would talk to the patients and then, you know, you come back around another month or two later and I found that things hadn't moved. So, it was really important to have a structure, you know, to ensure that we could move in an organized manner. So, we have established a very clear structure where we have them on our tracking board, and there are people that are assigned roles as to which part of the access placement and the follow up they're going to take on until we have them established at home.

Dr. Michael Kraus: Nothing succeeds without understanding where you are and where you want to go, and I think that's certainly working in Tulsa for us. Other physicians in your group or frankly, other physicians elsewhere in the country, what would you say to them? What tips would you give them to grow their home programs or move people in-center to home?

Dr. Alpana Pasricha: Everybody deserves a chance. There is so often that we think in terms of, oh, they're not candidates or what would they do? I have done this for so long. I have had so many patients that would have been considered borderline and they have succeeded. There is so much more we can do with home therapies for the patients and to improve their quality of life.

There is more than, you know, just limiting them to that three days, four hours a time. I think the physicians need some support. So, at my area, I offer them that if they run into problems, they should feel free to call me. I have been through so many difficult patients and have had the success, the fact that they can reach out to somebody and run their problems, I think gives them a lot of assurance that they aren't going to be stuck there by themselves.

Dr. Michael Kraus: We should say that Dr. Pasricha is one of our very good Physician Home Champions, and we have 35 of them around the country. So, we can always find somebody to talk to you if you have questions. Scott, you've seen the benefits of home therapies and what it's done for your patients, and you've been part of the process of growing. How is it we can move to where we are to make more home therapies more available to your patients?

Scott Ochs: One thing I learned a few years ago is that, you know, I had assumed that nurses especially and technicians included in the in-center space had a pretty good idea of what home therapies looked like, had a good idea of what PD and HHD were like. And what I what I learned was that there's a pretty big gap in in their education.

And so we worked really hard in my former region to make sure that they got the experience to touch and understand what it’s like to run a next stage machine. What's it like to do peritoneal dialysis? And what I found is that every single one of them said, you know what? If I had to do a dialysis, I would do one of these.

And when they got there, then it's a different conversation with patients, right? You're talking to a patient about, hey, this is what I would choose for myself, and this is what I would choose for my family members. So, we can't underestimate the fact that our in-center nurses and techs may have not gotten really good training on the modalities for home dialysis. And so, it's important to make sure that they fully see that and understand the benefits and the opportunity we have to improve the lives of our patients. 

Dr. Michael Kraus: And I agree. And I would say that as a physician or a nurse or tech, there's absolutely nothing wrong with saying, if I had kidney failure, this is what I would do. That's perfectly fine. And while we’re there, Dr. Pasricha, I'm always asked as you are, I'm sure, why aren't we going home and what are the problems? And frequently, it seems to me it's the barriers. Physicians, nurses underestimate who's going to do well at home and are reluctant to give them that chance. What, clearly, I think you share with me is people are not too sick to go home. They’re frankly too sick not to go home. Is that your experience as well?

Dr. Alpana Pasricha: Yes, truly. The only patients that belong to in-center are either the nursing home residents or maybe the homeless. That's what I believe. In fact, I think the sicker patients do better at home.

Dr. Michael Kraus: I agree. And your case showed us that a non-adherent patient does better at home as well. For physicians as patients, care team members and family members of dialysis patients listening out there, please explore home dialysis. See the benefits for yourself. Dr. Pasricha, Scott, thanks for being here today.

Dr. Alpana Pasricha: Thank you.

Scott Ochs: Thank you, Dr. Kraus. Great to be here.

Dr. Michael Kraus: And to our audience, thank you for joining us. If you're new to the Field Notes podcast, you can find us and download us on past episodes on the Apple Store or Google Play or right here at FMCNA.com. And while you're on FMCNA.com, subscribe to receive the very latest updates as they happen. Until next time, I'm Dr. Michael Kraus and you've been listening to Field Notes by Fresenius Medical Care North America. Take care, everyone.