Navigating Infection Control and Dialysis Delivery in Nursing Homes: Organizational Perspectives From 2020 to 2025

OBJECTIVES: Nursing home (NH) residents with end-stage kidney disease requiring thrice-weekly hemodialysis faced challenges during the COVID-19 pandemic, as infection control imperatives conflicted with access to life-sustaining care. This study examines how NHs and dialysis organizations navigated dialysis care for NH residents from 2020 to 2025, exploring how pandemic-era adaptations continue to shape care delivery. DESIGN: Descriptive qualitative study that synthesized interview data from the qualitative arms of three mixed-methods studies conducted between 2020 and 2025. SETTING AND PARTICIPANTS: Participants included NH administrators, clinical staff, and residents, as well as Medicare Advantage plan executives, kidney care management company leadership, and dialysis organization administrative leadership and staff across diverse US health care markets. METHODS: Semistructured interviews were conducted. Interview transcript coding used a modified grounded theory approach. Theme and subtheme development used thematic and content analysis. RESULTS: Three hundred nine interviews were conducted with representatives from 66 NHs, 8 Medicare Advantage plans, 5 kidney care management companies, and 6 dialysis organizations. Three themes were identified, reflecting varied perspectives on the impact of the COVID-19 pandemic on dialysis care for NH residents. First, during the pandemic, NHs and dialysis centers prioritized infection mitigation through spatial distancing, cohorting, extended quarantine protocols, and reduced admissions of residents requiring dialysis. Second, NH residents experienced significant barriers to dialysis access, including transportation and schedule disruptions. Third, the pandemic continues to affect dialysis care for this population: although infection control practices have become routine, transportation challenges remain unresolved, and many NHs have reduced admissions of dialysis-dependent residents, threatening access for this vulnerable population. CONCLUSIONS AND IMPLICATIONS: Although the COVID-19 pandemic prompted more rigorous infection control practices at NHs and dialysis centers, it also intensified longstanding vulnerabilities in cross-sector health care coordination for NH residents requiring dialysis. Insights from this study's findings could inform efforts to design more resilient, better coordinated models of care.