Identifying barriers to implementing an assisted home hemodialysis program in Canada

Background: Policy changes such as the Advancing American Kidney Health Initiative and the impact of the COVID-19 pandemic will accelerate the trend for more home dialysis Expanding the pool of patients eligible for HHD will require health care practitioner assisted models to be developed and deployed We hypothesize that many barriers to delivering assisted HHD (aHHD) exist and implementation of a successful program would require meaningful input from frontline home dialysis nurses Our primary objective of this study is to survey these key stakeholders to identify these barriers Methods: We conducted a semi-structured focus group of leaders within our large Canadian home dialysis program to anticipate key aspects of implementing aHHD, including gauging local demand, identifying eligible patients, and recognizing essential operational components From this, we constructed questionnaires for frontline nursing staff within HHD, peritoneal dialysis (PD) and assisted PD (aPD) programs We performed a qualitative analysis to identify common themes and implementation barriers Results: Twenty-six responses from three sites were received 20/21 PD nurses reported existing aPD programs expanded the eligible pool of PD patients 5/5 HHD nurses felt an aHHD program would keep more patients on the modality and prevent technique failure Only 2/5 felt aHHD should be offered as a transition to HHD While 18/21 PD nurses reported they could easily identify patients for aPD, only 2/5 HHD nurses agreed Patients with sensory deficits, functional impairments, and limited support networks were felt to benefit most from aHHD Lack of confidence and phobias were not agreed upon Behavioral and safety issues, clinical instability, and inability to manage emergencies may be barriers to aHHD Machine set-up, take-down, and establishing access were thought to be essential services PD nurses felt clinical assessments should be routine Few nurses felt complete assistance was necessary Conclusions: Our findings suggest there is a strong local demand for aHHD provided there is a clear criterion for enrollment and operational plans are well established Frontline nurses have identified several important barriers to implementation which we will acknowledge and address when deploying our assisted home program over the upcoming year