Area of Focus 4

Detailed Results


The fourth and final category identified in the four pillars of success involves monitoring and intervention. It is important to consider what happens after a patient has been successfully trained. For many patients the hardest part of home therapy lies in the first 90 days they are at home. Closely monitoring their successes and challenges at home helps identify those that might be at risk of discontinuation.

One of the potential solutions may be respite care. Respite care that is offered as part of the patient’s dialysis journey may help avoid patient and/or care partner burnout.

Based on Medicare claims data analysis we know patient discontinuation is 3X higher in patients who have been hospitalized during the prior month of home therapy. Admissions were typically due to fluid overload or infection which were common, but may be preventable with better volume management and infection control.1

Nx2me Connected Health is another option that can help facilitate both active monitoring and intervention. Flowsheets are sent electronically after each treatment and tracked and managed If patient parameters are captured outside their norm the report is flagged and the clinician can take timely action.

“Be there for your patients. After they go home, your training hasn’t stopped. Monthly education and follow-up are just as important as the training they get when they first started.”

Whether or not your facility has the ability to use a connected health platform, such as Nx2me, there are other opportunities to monitor and intervene that can be used.

Frequent Follow-up

  • When patients are trying something new, try having a nurse support them for first-time
  • Perform weekly calls to check-in and reinforce you are there to help support them even though they are now treating at home

Active Intervention

  • At sight of missed treatments or an infection, touch base and set-up additional training or calls as needed.
  • Reinforce training with the team member that makes the most sense, this could be a PCT to reinforce aseptic technique or cannulation, or a Bio-med to help them troubleshoot a system question.
Resources to Help

Review some of our additional resources to help encourage active participation and patient management including steps nurses can take to reinforce training or help patients during those first 90 days home.

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