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Kidney Patient Job Retention:. The Next Rehab Frontier Dori Schatell, MS Medical Education Institute, Inc. Medical Education Institute. MEI Mission: Help people with chronic disease learn to manage and improve their health MEI has worked on or developed: Original DOQI guidelines

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Kidney patient job retention

Kidney Patient Job Retention:

The Next Rehab Frontier

Dori Schatell, MS

Medical Education Institute, Inc

Medical education institute
Medical Education Institute

  • MEI Mission:

    Help people with chronic disease learn to manage and improve their health

  • MEI has worked on or developed:

    • Original DOQI guidelines

    • Life Options™

    • Kidney School™

    • Core Curriculum for the Dialysis Technician

    • Fistula First

    • Medicare Dialysis Facility Compare website

    • Home Dialysis Central

Sen hartke testimony 1972
Sen. Hartke Testimony: 1972

“60% of those on dialysis can return to work but require retraining, and most of the remaining 40% require no retraining whatsoever. These are people who can be active and productive,

but only if they have the

life-saving treatment

they need so badly.”

Kidney patient job retention

Life Options Rehabilitation Program

Dedicated to helping people live long and live well with kidney disease

Age of esrd patients
Age of ESRD Patients

52% of incident ESRD patients are <65

N= 607,329

Data Source: USRDS 2003 ADR, Table C4, Incident ESRD Patients 1995-2002

Education of esrd patients

N = 1599







Education of ESRD Patients

Schatell D, Klicko K, Becker BN. Am J Kidney Dis. 48(2):285-91, 2006.

Job loss is the rule patients age 18 55 at 90 days post initiation may 1995 june 2001
Job Loss is the RulePatients Age 18-55 at 90 Days Post Initiation, May 1995-June 2001

Data Source: USRDS Special Data Request 2003

Job loss disability can impoverish esrd families
Job Loss/Disability Can Impoverish ESRD Families

Effect of job loss on patients
Effect of Job Loss on Patients

“Hi my name is X, i’ve been on dialysis for 3 years and im only 36 years old. i got it from high blood pressure.

well now i have no friends and im depressed and my life sucks. im a single person with no job and no life. dialysis sucks and i should just die.”

Actual quote from the dialysis_support listserv, March, 2006

Effect of job loss on patients1
Effect of Job Loss on Patients

“I've been on hemo for 11 years now. I lost my job at Central Texas College because keeping up with dialysis and my job was just too much. I lost my wife of 22

years and 3 children to another man because I began to have sexual difficulties as a result of renal failure, which by the way, Cialis, Viagra and Levitra just doesn't help.I've developed carpal tunnel syndrome as a result of calcium deposits in the wrists. And then try to live on an SSI payment of $603.00 a month. It isn't easy let me tell you. Since my divorce 7 years ago I have been bouncing between friends. That's no life.”

Actual quote from the dialysis_support listserv, August, 2006

Benefits of work for patients
Benefits of Work for Patients

  • Self-esteem

  • Higher income1

  • Health insurance2

  • Built-in social outlet

  • Better physical functioning3

    1Insurance Information Institute,

    2USRDS Special Data Request, May 20, 2003

    3Blake et al. Physical function, employment, and quality of life in end-stage renal disease. J Nephrol 13(2):142-149, 2000

Functioning well being pcs mcs scores
Functioning & Well-being: PCS + MCS scores

Mental Component Summary: MCS

Physical Component Summary: PCS

Employment and fwb
Employment and FWB

  • Employment predicted PCS and MCS in African American CKD patients

Kusek et al. Cross-sectional study of health-related quality of life in African Americans with chronic renal insufficiency: The African American Study of Kidney Disease and Hypertension Trial. Am J Kidney Dis 39(3):513-524, 2002

Kidney patient job retention

FWB Scores Predict Morbidity & Mortality

  • 1 Point  in MCS

  • Mortality rate 0.46%

  • Hosp. rate 0.23%

  • 1 Point  in PCS

  • Mortality rate 0.43%

  • Hosp. rate 0.43%

Lowrie EG et al. Medical Outcomes Study Short Form-36: A consistent and powerful predictor of morbidity and mortality in dialysis patients. Am J Kidney Dis 41(6):1286-1292, 2003.

Benefits of work for providers




~ $350 per


+ 4x meds


~ $130 per


+ meds

Renal Community

Benefits of Work for Providers:

Two Dialysis



Payer mix dialysis revenues
Payer Mix & Dialysis Revenues

Dialysis Revenue Sources

Payer Mix: Community-wide

Clinic revenue per patient year medicare only vs employer group insurance
Clinic Revenue Per Patient/YearMedicare-only vs. Employer Group Insurance

1 year impact pt job retention vs composite rate
1-year Impact: Pt. Job Retention vs. Composite Rate

  • Increased revenue to the renal community of a 2.0% composite rate increase for 377,313† patients:

    $135 million

  • First-year revenue to the renal community if previously-working patients kept working*:

    $183 million

    *6,922 patients in 2002 were working 6 months prior & not at initiation

    †2005 projected population assuming 7% growth/year

Job loss is the rule patients age 18 55 at 90 days post initiation may 1995 june 20011
Job Loss is the RulePatients Age 18-55 at 90 Days Post Initiation, May 1995-June 2001

Data Source: USRDS Special Data Request 2003

Kidney patient job retention

How Do We Keep Patients Working?

To keep patients working
To Keep Patients Working…

  • Reach patients early with information

  • Treat predialysis anemia

  • Offer work-friendly treatments

  • Create an expectation that work is possible

Reach patients early with information
Reach Patients Early with Information


  • % of patients who get predialysis education?

How can networks reach patients early
How Can Networks Reach Patients Early?

  • Partner with:

    • QIOs

    • Industry

    • Media

    • Centers for Disease Control & Prevention

    • Nephrologists

    • Voluntary organizations

Treat predialysis anemia
Treat Predialysis Anemia

“Not being able to get up in the morning and be awake— it almost feels like you need another 2 or 3 hours of sleep. And when you get home from work or from a dialysis treatment, you’re not just tired, you’re utterly exhausted. So it’s not like you come home and do something else. You come home and sleep.”

Treat predialysis anemia1
Treat Predialysis Anemia

“I finished my garage—I put up some pegboard and some insulation. It took several weekends because I couldn’t do it myself; I had a helper come over. And at 40 [Hct], I could hammer nails. At 36, I couldn’t. I’d take 2 or 3 swats at the nail and then I’d be

winded. That’s kind

of incredible, isn’t it?”

Treat predialysis anemia2
Treat Predialysis Anemia

“I have pretty good energy and I play 9 holes of golf, but when it [Hct] gets below a certain level, my energy is shot. I’ll walk to the mailbox, which is about 50 feet, and I’ll have to stop and rest a while.”

Offer work friendly treatments
Offer Work-Friendly Treatments

Patients Age 18-55 at 90 Days Post Initiation, May 1995-June 2001

Chi Square 247.711756752216, df = 2, p≤ 0.001

Data Source: USRDS Special Data Request 2003

Offer work friendly treatments dialysis choices 2003 n 324 826
Offer Work-Friendly TreatmentsDialysis “Choices” 2003N = 324,826

USRDS 2005 Annual Data Report, Table D.1

Patients not told all options 1997

Before their first treatment

Patients told of in-center hemo: 89.7%

In-center patients told of HHD: 24.6%

In-center patients told of PD: 25.1%

Patients Not Told All Options: 1997

USRDS 1997 Annual Data Report, USRDS Dialysis Morbidity and Mortality (Wave 2), p. 53.

Patients not told all options 2005

Among all incident patients in California:

Patients not aware of PD: 66%

Patients not aware of home hemo: 88%

Patients not aware of transplant: 74%

Patients Not Told All Options: 2005

Mehrotra R et al, Kidney Int 2005 Jul;68(1)378-90.

What makes a treatment work friendly
What Makes a Treatment Work-Friendly?

  • Flexible or patient-centered schedule

  • Fewer symptoms & hospitalizations

  • Less restricted diet & fluids

Communicate the relative burdens of dialysis

No schedule control

Strict diet/fluid limits

“Dialysis hangover”

Other patient deaths

Travel to/from clinic

Time off work/school

No choice of stick-er

Travel planning…

Putting in needles

Dialysis emergencies

Order/store supplies

Space for equipment


Doing treatments

Alarms at night


Communicate the Relative Burdens of Dialysis



Kidney patient job retention

Physiology of 3x/week


No normal range of ECV, K, Bicarb, P, Ca, pH








Kidney patient job retention

Physiology of Daily Dialysis

Normal range of ECV, K, Bicarb, P, Ca, pH








Work friendly treatments capd
Work-friendly Treatments: CAPD

  • Training takes 1 week

  • Patient sets schedule

  • Preserves residual renal function longer

  • Transplant is more likely

  • 1,549 US clinics

Work friendly treatments ccpd
Work-Friendly Treatments: CCPD

  • Abdominal catheter needed

  • Cycler does exchanges

  • Possible manual exchange/day

  • Training: 1-2 weeks

  • 1,524 US clinics



Fresenius Newton

IQ Cycler


HomeChoice Pro


Freedom Cycler

What patients say about pd
What Patients Say About PD


"PD and work go well together. I feel fine after doing my exchange. PD is closer to what I want out of life.”

“I thought about doing hemodialysis at the dialysis center, but the people looked so wiped out after their dialysis. Plus, I didn't have the time to go in there 3 times a week. I've got work to do!”

"I am so afraid of needles. I was only a little kid when I had my first needles and problems with my fistula. If you have to do dialysis, this is the way to go!"


Mary Ann

Tish Sandoval

Work friendly treatments daily home hemo
Work-Friendly Treatments: Daily Home Hemo

  • 2-2.5 hrs, 5-7 times/week

  • Training 2-8 weeks

  • Trained partner needed

  • 132 USclinics


Allient Sorbent


System One

Aksys PHD

What patients say about daily home hemo
What Patients Say About Daily Home Hemo

"I feel so much better. I dialyze seven times a week."

“I feel great now! I have no up-and-down days and I feel very similar to when I had no kidney failure.”

"People shouldn't live to dialyze but to have a life and do the things they were meant to do."

Dadi Ding

Jake Casey

Bill Peckham

Work friendly treatments nocturnal home hemo
Work-Friendly Treatments:Nocturnal Home Hemo

  • Done 7-8 hours, 3-6 nights/week

  • Training takes 4-8 weeks

  • Trained partner is needed

  • 127 US clinics

What patients say about nocturnal home hemo
What Patients Say About Nocturnal Home Hemo

"Now, I am able to work full time and fit my treatments into my life!”

“On in-center dialysis, I felt like I was in prison. I couldn't eat a tomato, eat cheese, or drink milk. Now, you have control. You have your life back.”

“People who don't know that I'm on dialysis can hardly even tell that I'm sick."

Melissa Bensouda

Sarah Taxman

Wanda Wilson

How can networks offer work friendly treatments
How Can Networks Offer Work-Friendly Treatments?

  • Include information in patient & professional newsletters & meetings

  • Track & report availability by Network

  • Gather thought leaders & practitioners



Create an expectation that employment is possible
Create An Expectation ThatEmployment is Possible

  • Share success stories in newsletters or bulletin board displays

  • Track & report employment data

  • Include job retention as a topic in meetings & QI initiatives

  • Offer Life Options Patient Interest Checklists (


  • Job loss is the rule—but job retention benefits patients, clinics, & the government

  • Half of all ESRD patients are working-age

  • ESRD Networks can help by:

    • Reaching patients early with information

    • Encouraging treatment of predialysis anemia

    • Offering work-friendly treatments

    • Creating an expectation that work is possible