Dialysis, a medical procedure that removes waste products and excess fluid from the blood when the kidneys can no longer perform this function, is a necessity for individuals with End-Stage Renal Disease (ESRD). A skilled nursing facility (SNF), commonly referred to as a nursing home, is a residential setting that provides a range of medical and personal care for residents who require continuous nursing supervision or rehabilitation. While a nursing home’s primary function is to provide long-term residence and skilled care, federal regulations mandate that these facilities must ensure their residents receive all necessary services, including dialysis. This means that while a nursing home may not operate a dedicated dialysis clinic, it is legally required to facilitate the life-sustaining treatment for its residents.
Dialysis Services in Nursing Facilities: Availability and Delivery
The traditional model for delivering hemodialysis (HD) to nursing home residents involves transporting the patient to an outpatient End-Stage Renal Disease (ESRD) facility three times each week. This approach is prevalent because most nursing homes lack the specialized equipment, water purification systems, and dedicated clinical staff required to perform HD treatments on-site. The logistical burden of this model is significant, involving arranging non-emergency medical transportation and coordinating the resident’s schedule around the four-hour treatment sessions plus travel time. This frequent, lengthy travel can be taxing on the patient, potentially leading to missed rehabilitation sessions or meals within the facility.
A growing, though still rare, alternative is the provision of on-site HD within the nursing home, achieved through a partnership with an external ESRD provider. This model often utilizes portable dialysis machines and is delivered either at the resident’s bedside or in a dedicated treatment area known as a “den.” Providing the service in-house eliminates the need for disruptive transportation and can improve the resident’s quality of life and adherence to their care plan. The nursing home collaborates with the ESRD provider, ensuring a safe environment and monitoring the resident before and after the procedure.
The ESRD provider maintains responsibility for the dialysis treatment, including equipment and specialized staff. When hemodialysis is performed on-site, a trained registered nurse (RN) from the provider must constantly supervise the treatment. Nursing home staff are responsible for all non-dialysis related care and must be prepared to respond to any dialysis-related complications or emergencies. This collaborative arrangement allows the nursing home to meet its regulatory obligation without becoming a licensed dialysis center.
Managing Peritoneal Dialysis in Long-Term Care
Peritoneal Dialysis (PD) is a less logistically complex option for residents in long-term care settings compared to hemodialysis. This form of dialysis uses the resident’s peritoneal membrane as a natural filter, involving the periodic infusion and drainage of a specialized solution through a catheter placed in the abdomen. Because PD does not require complex machinery or a specialized water source, it can be performed directly at the resident’s bedside, often while they are sleeping, using an automated cycler machine.
This bedside delivery significantly reduces the need for disruptive, three-times-weekly transportation to an external clinic. The nursing home’s primary responsibility is ensuring the PD procedure is carried out using strict sterile technique to prevent peritonitis, an infection of the abdominal lining. Licensed nursing staff, such as RNs and Licensed Practical Nurses (LPNs), must be trained by the ESRD provider to assist with cycler setup, monitor the fluid exchanges, and recognize complications.
The success of PD relies on a systematic training program for the facility’s personnel and consistent support from the resident’s nephrology team. The external dialysis unit typically supplies all necessary dialysis solutions and related medications to the SNF. Integrating the treatment into the resident’s daily routine allows patients to participate more fully in daytime activities and rehabilitation programs.
Understanding the Costs and Payment Structure
A key financial distinction is that the nursing home stay and the dialysis treatment itself are billed separately to the payer. Payment for the nursing home stay can come from various sources, including Medicare Part A for short-term skilled nursing and rehabilitation, or from Medicaid and private funds for long-term custodial care. This payment covers the resident’s room, board, general nursing care, and other services provided by the facility.
The actual dialysis treatment—the procedure, specialized equipment, supplies, and professional services of the nephrologist—is typically covered under Medicare Part B. Medicare pays a bundled rate to the ESRD facility for the treatment, which includes most ESRD-related drugs and laboratory tests. For patients with Original Medicare, the beneficiary is generally responsible for the Part B annual deductible and a 20% coinsurance of the Medicare-approved amount for each treatment session.
When dialysis is provided, the ESRD facility must bill Medicare Part B, regardless of whether the resident receives treatment in an external clinic or on-site at the nursing home. One potential out-of-pocket cost for the resident, which is not covered by the treatment bundle, can be non-emergency medical transportation fees if the nursing home does not include this service in its daily rate or if the resident’s supplemental insurance does not provide coverage. These transportation costs can accumulate quickly since the treatments are required multiple times a week.