Despite evidence that clinical outcomes for patients treated with peritoneal dialysis or home haemodialysis are better than for patients treated with conventional satellite or hospital-based haemodialysis, rates of home-based dialysis therapies world-wide remain low. Home-based dialysis care is also cost effective and indeed the favoured dialysis option for many patients.
Using a lean-thinking framework and established change management methodology, a project embracing a system-wide approach at making a change where a Home before Hospital philosophy underpinned all approaches to dialysis care was undertaken. Three multidisciplinary working groups (Pathway, Outreach and Hybrid) were established for re-design and implementation. The primary aim was to improve home-based dialysis therapy prevalence rates from a baseline of 14.8% % by ≥2.5 %/year to meet a target of 35%, whilst not only maintaining but improving the quality of care provided to patients requiring maintenance dialysis.A future state pathway was developed after review of the current state (Pathway Working Group) and formed the basis on which a nurse-led Outreach service (Outreach Working Group) was established. With the support of the multidisciplinary team, the Outreach Service model focussed on early, consistent, and frequent education, patient support in decision making, and clinician engagement.
A target prevalence of >30 % for home-based therapies (mainly achieved with peritoneal dialysis) was achieved within 2 years. This prevalence rate reached 35% within 3 years and was maintained at 8 years. In addition, selected patients already on maintenance satellite-based haemodialysis (Hybrid Working Group) were educated to achieve high levels of proficiencies in self-care.
Having the system-wide approach to a Quality Improvement Process and using established principles and change management processes, the successful implementation of a new sustainable model of care focused on home-based dialysis therapy was achieved. A key feature of the model (through Outreach) was early nurse-led education and support of patients in decision making and ongoing support through multidisciplinary care.