Step 2: Feasibility
A business plan requires the realistic projections of the costs and accounting for gains of the new clinical program. While there is limited guidance on personnel requirements when planning a PD program, we provide estimated resources needed to successfully establish and run a PD program (eAppendix 1, available online at doi:10.12788/fp.0356).
Clinical Considerations
Secondary or tertiary care VAMCs with multiple medical and surgical specialties routinely provide complex inpatient care. For these facilities, the lack of inpatient PD poses an obstacle to the provision of specialized nonnephrology care to veterans with ESKD, who are frequent users of such complex care. These considerations argue for the need for at least inpatient PD services at VAMCs that provide complex medical care for many veterans receiving PD in the community.
Deliberations for outpatient PD programs should be based on the clinical demands of ESKD care, the number of veterans likely to use PD, and growth projections. While there is no established minimum number that guarantees cost-effectiveness, most existing VA outpatient PD programs provide services for about 5 to 25 veterans. A local census can provide estimations of future PD needs. Travel considerations (ie, distance, terrain, traffic) may affect eligibility for purchased care and the decision where to receive PD. Many veterans may prefer PD from the local VAMC if it is convenient and allows them to maintain centralized VA care. Potential patients can be surveyed to gauge interest in receiving VA-based PD. Facilities providing structured pre-ESKD KDE may hold greater potential for PD growth, and it is important to highlight KDE infrastructure in the business plan.
Infrastructure
Spatial needs including clinic space and storage space for consumables, supplies, and equipment should be part of infrastructure requirements. The program champion may need to examine the available space for suitability and adequacy of the PD program early in the process. Ventilation renovations in the PD rooms should be incorporated into budget calculations. Water access for handwashing and PD effluent drainage should be confirmed, and if the program intends to establish home HD, additional considerations for the storage and water supply may be required. The VHA Handbook outlines the infrastructure requirements for a dialysis program.22 The VA has established national vendor contracts for dialysis equipment and consumables. However, a new PD program may need further guidance regarding the local agencies that provide administrative support and assist patients.
Telehealth technology has enabled many VAMCs to overcome geographical barriers for rural veterans.23 Ongoing expansion of community-based outpatient clinics (CBOCs) to include more rural locations is improving access to specialty care, while the launch of VA Video Connect (VVC) has further improved outreach. Investigators from Minneapolis have demonstrated the feasibility of multidisciplinary home-based telehealth management of veterans with CKD.24 Several existing nephrology sections across the VHA use a combination of VVC and CBOC-facilitated clinic visits to provide some pre-ESKD and ESKD care, including KDE, PD home visits and training, and comprehensive ESKD care visits. Recent changes in the clinical care pattern during the COVID-19 pandemic have further eased ESKD telehealth protocols. Integrating the projected use of telehealth in collaboration with existing resources available through the VHA NKDP can allow the local champion to improve the financial feasibility and long-term success of a new PD program.