Noncompliance for chronic hemodialysis patients is multi-factorial. Improving compliance is the responsibility of everyone but the end result, either positive or negative lies with the patient. As providers, we owe it to our patients to work with them as to reasons and reasonable solutions.
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Why are chronic hemodialysis patient noncompliant? This is the $64,000 question. With Medicare demanding more and more from providers, we must get creative in ways to encourage our chronic hemodialysis patients. First, we need to explore why our patients AREN'T compliant:
* Could it be coming to an outpatient dialysis unit takes too much time?
* Do they have transportation issues?
* Is childcare an issue?
* Have they been on dialysis for many years, not eligible for transplant and see no future?
Chronic outpatient hemodialysis in the US is typically three times per week for four hour sessions. It can range from 3 hours to as long as 5+ hours as it is roughly based on your body mass. So, it does take time. Can we give the patient some choice in times? Perhaps they are a morning person, want to come in at 5:30am, do their treatment and get one with their day. They may work during the day and want to come in the evening and then go home and sleep. Nursing home patients are typically scheduled during the middle of the day due to transportation arrangements.
Speaking of transportation, do the patients have reliable transportation? What options are there for public transportation, perhaps a cab would be an option. In Illinois, for instance, where I live, Medicaid funds cab rides to and from medical appointments for some of the patients. Can a carpool be arranged? If there primary means of coming to dialysis isn't available, what alternatives are in place?
Many newly diagnosed end stage renal disease patients are young with young children at home. Do they have reliable daycare? Is it affordable? Are they feeling up to caring for children after dialysis? Is there another caregiver for the children? And...finally, are they hopeless? Does the patient feel as though there are no alternatives except outpatient hemodialysis? Have the options including peritoneal (PD) , nocturnal hemodialysis (if available in your area), home hemodialysis been explained fully to the patient.
Lots of questions, not a lot of answers. However, we can start to get answers by asking patients, what's up? We missed you last time, is there something we can do to help you best care for yourself? It all comes down to buy-in - the patient needs to feel they have some control and are in the driver's seat. Sadly sometimes the only way they can demonstrate this is to be noncompliant.
