Home DialysisImprovement project

Why?

• Home dialysis• Includes PD and HD

• Includes self and assisted care models

• Benefits• Personal

• Medical

• Quality of life

• System• Resources

Guidance

• Professional guidance• NICE

• 2002 https://www.nice.org.uk/guidance/ta48

• Renal Association• Peritoneal Dialysis in Adults and

Children June 2017

• Research evidence

• Patient organisations

Attitudes positive in the main …..

BMC Nephrol. 2014 Jan 15;15:16. doi: 10.1186/1471-2369-15-16.

…… but disconnect with delivery

UK Renal Registry 18th Annual Report

Variation across UK is high

0.0

5.0

10.0

15.0

20.0

25.0

Carsh L Barts L Guys L Kings L Rfree L St.G L West

Data taken from UK Renal Registry % prevalent patients on home dialysis modality

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

Progress is slow (or stagnant) Fall in PD > growth in HHD

UK Renal Registry 18th Annual Report

Why?

• 185 respondents • 50% at meeting

• MDT mix (30% medic, 35% nurse)

• Resources – red

• Patient factors – dark blue

• Service factors – light blue

All respondents Low leadership barrier

Responses

Answer Options Rating Average (all) Rating Average Low leadership barrier

Reimbursement for home dialysis (i.e. what centres get paid) 2.21 2.00

Equipment, consumables and installation cost 2.42 2.22

Patient housing unsuitable 2.91 2.82

Patient and carers choice or desire 2.82 2.63

Patient frailty or illness 3.14 3.04

Staff knowledge and confidence 2.40 2.10

The in centre HD unit referral rate 2.57 2.21

Pre dialysis team referral rate 2.21 1.92

Business planning or management support 2.70 2.32

Champions or leaders for home therapies 2.25 1.52

Bias from clinical teams 2.48 2.07

Resources for training of patients and carers 2.60 2.33

Patient knowledge and confidence 2.80 2.60

Resources to support people at home 2.72 2.48

Why?

• Financial concerns were not the main barriers.

• Strong leadership and a positive organisational culture were the main contributors towards successful home dialysis programmes.

• Change management skills to deliver sustainable, systematic and evidenced change are needed.

• Patient factors – frailty, choice – were important determinants, but less so in some leadership systems.

Manchester Home Dialysis Forum 2016 Workshops

To increase the proportion of patients on home dialysis therapies in England

Clear Vision & Purpose

Leadership

i) Organisational ii) Medical iii) Nursing iv) Patient Leadership

Organisational Culture

Values, behaviours & mindset

Expertise [Knowledge& skills]

Patients

Determining ‘suitable’ home dialysis patients

Develop patient exclusion criteria, dependent on local expertise

Home dialysis training

Effectiveness & experience of training pathway

Patient awareness, recruitment & retention

Patient Education & Informed Choice; Patient & carer experience;

Peer support; Carer support

Organisational Infrastructure

Financial support

Training facilities

Commissioning dialysis consumables and machines

Home modifications

Access to respite care

Multidisciplinary team supported by community team

DRIVER DIAGRAM: Home Dialysis

The KQuIP proposal

• A national improvement project

• Based upon regional collaboratives or networks

• Central support from KQuIP

• Coproduction

Perception of suitability

X

System efficacy

=

Probability of home dialysis

Leadership

Skills, knowledge and confidence

Culture

Measurement

How?

• Our Shared Vision

• To reduce regional variation and improve delivery of home dialysis in order to

• Improve the experience of care of individual patients and their families

• Improve the value of care by improving outcomes at the same or reduced cost.

• Sponsored by national stakeholders

• Operational support from UKRR KQuIP team

• Regional networks supported by project management time

• Regions to establish regional teams and provider teams to lead work – MDT & service user integrated

Three phases to improvement at network level• Step 1: Research and discovery

• What works well, regionally or nationally?

• What can you use or adapt?

• How will you measure success?

• Step 2: Ideas

• Develop long list of ideas

• Refine list by discussion

• Agree final list

• Step 3:

• Test ideas• Agnostic to QI methodology• Embrace uncertainty • Collect evidence

• Present and refine (or abandon)

• Repeat cycle

Start PD pathway

Plan dialysis access - insert PD catheter

Patient and MDT sign off for PD pathway

Assess for suitability– clinical, patient factors and home suitability

Screen low clearance, Prevalent HD, Incident HD, Failed Tx

Identify potential PD patients through shared decision making

MDT review

Next steps

• Funding

• Project plan

• Steering committee established

• Define data set• Clinical• Patient – PAM, PREM, PROM• Process measures• Balancing measures

• Network applications

• Launch for project initiation Sept 2017

• Project start (network 1) April 2018