Table 4.

Suggestions for overcoming clinician barriers to providing home haemodialysis

Barriers	Potential solutions
Lack of awareness and experience in home haemodialysis	▸ Convene regional and national professional education seminars on home haemodialysis ▸ Incorporate home haemodialysis training in nephrology training programmes ▸ Develop and disseminate clinical practice guidelines on home haemodialysis ▸ Organise short-term visits to other centres to gain practical experience ▸ Identify local champions (professional advocates) for home haemodialysis ▸ Disseminate home haemodialysis ‘success stories’ through meetings, newsletters, nephrology society communiqués ▸ Establish centralised home haemodialysis training units to conserve resources and attract training staff
Concern about patient safety, adequacy of support, and psychosocial burden	▸ Facilitate collaboration and interaction with professionals who have extensive experience with home haemodialysis ▸ Develop policies addressing patient safety including 24-h availability of technical and medical support; patient and carer training, individualised patient assessment for home visits or paid carers; patient access to a ‘parent dialysis centre’ in case of complications; regular patient contact; dedicated psychologist/social worker ▸ Ensure laboratory results can be tracked easily by patients and providers ▸ Coordinate independent accreditation to ensure quality of equipment and dialysis solutions; and conducive home environment ▸ Increase knowledge about the potential clinical benefits of home haemodialysis (use data of current practice to establish an evidence base to support research, which will reflect efficacy of outcomes of home programmes; and encourage participation in RCTs of home dialysis versus in-centre dialysis to strengthen evidence base for home HD) ▸ Educate clinicians about the availability of current ‘patient-friendly’ home haemodialysis machines (smaller size, minimise need for a family carer to assist) ▸ Demonstrate patient ability cope with home haemodialysis (self-cannulation, operating simple machines) ▸ Emphasise the importance of fostering patient independence and self-care rather than a ‘learned helplessness’ ▸ Provide respite opportunities for home HD patients to avoid patient and/or carer ‘burn-out’ ▸ Promote further development of simplified home HD machines that are portable and don't require significant plumbing or electrical changes to home
Limited centre capacity in dialysis centres to establish home haemodialysis programmes	▸ Allocate resources and dedicated space for training ▸ Provide home HD training facilities that are geographically separate from in-centre HD facilities
Inadequate compensation and financial disadvantage	▸ Emphasise ‘patient-centred’ care within the organisational culture to minimise influence of commercial interests (eg, to incorporate patient-orientated key performance indicators) ▸ Implement centralisation of funding away from commercial interests and reduce physician reimbursement on a fee-for-service model ▸ Compensate clinicians for ‘hidden tasks’ including the planning and management of home haemodialysis programmes ▸ Provide additional financial incentives to units including reimbursement at a higher than cost level ▸ Develop public sector funding models that rewards home haemodialysis programmes (eg, provide incentive payments for home haemodialysis patients ▸ Defray patients’ out of pocket expenses for home HD (water, electricity)
Competing centre priorities	▸ Highlight the importance of equity of access to all dialysis modalities (eg, patients may prefer home haemodialysis to in-centre haemodialysis) ▸ Provide balanced patient education early in pre-dialysis phase emphasising all dialysis modalities available such that patients are allowed to make an informed choice.