NEPHROLOGY SOCIAL
WORK
Chapter 1 8
Handbook of
Health Social
Work, 2 nd
Edition
Created by
Teri Browne
END STAGE RENAL DISEASE AS A
PUBLIC HEALTH ISSUE
 End-stage renal disease (ESRD)- chronic condition
that results in kidney failure and necessitates renal
replacement therapy via hemodialysis, peritoneal
dialysis, or a kidney transplant (also known as
“chronic kidney disease stage 5)
 ESRD is an important practice focus for social work
because it provides the only Mediare mandate for
MSW service provision for a disease or treatment
category
THE CAUSES OF ESRD
ESRD is cause primarily by diabetes and
hypertension, but also by:
 Lupus
 Gout
 Chemotherapy
 Cancer
 Substance Abuse
 Other kidney diseases (glomerulonephritis, nephritis,
and polycystic kidney disease)
COSTS OF ESRD
 The average 2010 Medicare cost per patient for
hemodialysis was $77,506 per year
 The cost for peritoneal dialysis was $57,639
 The cost for kidney transplantation was about
$116,100 for the year in which the transplant was
received and $26,668 per year after the transplant
WHAT IS HEMODIALYSIS?
 Hemodialysis- a medical treatment in which a
patient is connected to a dialysis machine via
tubing joined to an external catheter in the
patient’s chest or needles inserted into a
permanent vascular access (also called fistulas,
grafts) that is usually in the arm which is attached
to tubing that leads to the machine.
 The machine consists of tubing, solution, monitors,
and a filtering device called a dialyzer that removes
excess fluid from the patient and cleanses the
blood prior to its return to the body through tubing
connected to the catherter or access.
WHAT IS HEMODIALYSIS?CONTINUED
 In-center Dialysis- usually performed three times a
week for at least three hours per treatment
 Monitored by nurses and patient care technicians
 Hemodialysis patients see the health care team while receiving
treatments
WHAT IS HOME HEMODIALYSIS?
 Home hemodialysis is a treatment option that allows
patients to perform their own dialysis at home
 Patients and social suport network members receive
comprehensive training
 Equipment and supplies are delivered and set up in
the home
 Home hemodialysis provides a more comfortable
environment for the patient and eliminates travel
 Patients see their dialysis teams when they return to
the dialysis clinic for laboratory testing and follow -up
visits
WHAT IS PERITONEAL DIALYSIS?
 Peritoneal dialysis is a renal replacement treatment
modality that is conducted by patients themselves
 A catheter is surgically implanted in patients that
protrudes from the abdomen
 This is dne daily, either several times throughout the
day or overnight via a machine
 Peritoneal dialysis patients see their healthcare
team during monthly visits to the clinic
WHAT IS KIDNEY
TRANSPLANTATION?
 Kidney transplantation is a surgical procedure in
which a donor kidney is placed in the ESRD patient’s
body
 The donor kidney can be deceased or a living donor
 It involves extensive evaluation and testing
 If a living donor cannot be located, the patient is
placed on a waiting list for a deceased donor kidney
WHAT ARE ALTRUISTIC KIDNEY
DONATIONS?
 An altruistic kidney donation is when a person gives
their kidney to someone they do not know personally
 A growing phenomenon in kidney transplantation is
called “paired donors”
 An example of paired donors can be found on page
470
A QUICK HISTORY OF DIALYSIS
 Acute dialysis was first done in the 1940s
 The first kidney transplant was performed in 1951
 Chronic outpatient dialysis was first available in the
early 1960s
 In 1965, there were only 200 dialysis patients in the
world
 Before 1972, hemodialysis machines were scarce
and dialysis was largely paid for by patients or with
donated funds
 Selection committees chose individuals for dialysis
based on their “social worth”
 Preference was given to breadwinners and community
leaders
A QUICK HISTORY OF DIALYSISCONTINUED
 On October 30, 1072- the national ESRD program,
Public Law 92-601 was passed
 This law provides Medicare coverage of dialysis or kidney
transplantation for all ESRD patients regardless of age
 This coverage is unique, because ESRD is the only disease
category that guarantees Medicare eligibility
DEMOGRAPHICS OF RENAL PATIENTS
 Individuals 65 years and older are the fastest
increasing population among ESRD patients today
 This group has more comorbidities, greater psychosocial issues
and needs, and more physical problems
 Certain groups in the United States are effected
disproportionately:
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African-Americans
Hispanics
American Indians
Alaskan Natives
 White American males are more likely to receive a
kidney transplant than any other demographic group
in the United States
REASONS FOR DISPARITIES
 Lack of preventative care
 Patient preference
 Socioeceonomic disadvantage
 Distrust of the medical community
 Lack of knowledge about kidney transplantation
 Medical reasons
PSYCHOSOCIAL ASPECTS
 89% of ESRD patients report experiencing significant lifestyle
changes from the disease
 Psychosocial barriers to ESRD care:
Adjustment and coping to the illness and treatment regime(s)
Medical complications and problems
Issues related to pain, palliative care, and end -of-life care
Social role adjustment: familial, social, and vocational
Concrete needs: financial loss, insurance problems, prescription
coverage
 Diminished quality of life
 Body image issues
 Numerous losses; financial security, health, libido, strength,
independence, mobility, schedule flexibility, sleep, appetite, freedom
with diet and fluid





DISEASE- RELATED PSYCHOSOCIAL
ASPECTS
 ESRD may impair sense of taste, diminish appetite and
cause bone disease that can require surgery and impair a
person’s ability to walk
 ESRD patients may have anemia and uremia, which lead
to confusion, lethargy, and sleep problems
 Dialysis patients often must take several phosphorous binding tablets with every meal as well as numerous
other medications (some take up to 25 pills a day)
 Self-management of oral medications is a significant problem
 Researchers have found ESRD patients to be significantly
more likely than others to commit suicide
ANXIETY AND DEPRESSION AMONG
ESRD PATIENTS
 Researchers have noted that ESRD results in anxiety
and depression
 More likely to have poor nutritional outcomes
 Higher mortality rate
 Malnutrition
 Less likely to adhere to their recommended treatment regimes
 Depression can lead to hospitalization
OTHER DISEASE-RELATED
PSYCHOSOCIAL ASPECTS
 Insomnia and sleeping problems
 Body image issues
 Vascular accesses for hemodialysis can become quite large
and visible on patients arms
 Peritoneal accesses and catheters are surgically implanted and
protrude from the body
 Immunosupporessant drugs and other medications can cause
weight gain and other physical changes
 Decreased rate of fertility among female ESRD
patients
 Acute and chronic pain from surgeries, cramping,
needlesticks, neuropathy, and bone disease
IMPACT ON FAMILIES
 Difficulty coping with the illness and treatment
regimes
 Financial burden/loss of income
 Extra time needed to care for patients and transport
them to treatments
 Limits work hours
TREATMENT-RELATED PSYCHOSOCIAL
ASPECTS
ESRD patients are required to assume strict
diets
Extreme weight gain between dialysis
treatments can lead to discomfort during
hemodialysis and removal of excessive fluid
results in severe cramping and low blood
pressure
Peritoneal dialysis patients have much less
restrictive dietary and fluid intake restrictions
Transplant patients normally are not required
to follow renal diets or limit their fluids
RAMIFICATIONS OF PSYCHOSOCIAL
ISSUES
 Barriers to quality diet may include patients’
education and literacy level
 Insurance may not allow patients to obtain
recommended nutritional supplements
 Social support availability is also related to poor diet
because ESRD patients may need assistance to
purchase groceries and prepare meals
SOCIAL WORK INTERVENTION
 The significant psychosocial issues faced by ESRD
and their families requires social work intervention
 This practice is known as nephrology social work, or renal
social work
 Medicare mandates that a master’s level social
worker be on staff in every dialysis center and kidney
transplant program
 The focus of these social worker’s is to imporove the
patients ability to adjust and cope with chronic
illness and the healthcare system’s ability to meet
the needs of the patient
SOCIAL WORK INTERVENTIONCONTINUED
 Social workers are included on renal medical teams
(which also include the patient, their family
members, the nephrologist, the nurses, dieticians,
patient-care technicians, surgeons, and pharmacists)
 Sudies show that a team approach to patient
education (which includes a social worker) is more
successful than a single-disciplinary approach
 A report on morbidity and mortality of dialysis by the
National Institutes of Health claims that social and
psychological welfare and the quality of life of the
dialysis patient are favorably influenced by the
involvement of a multidisciplinary team
SOCIAL WORK INTERVENTIONSCONTINUED
 Nephrology social work interventions tend to be
valued by patients
 1994 survey found that 90% of ESRD patients believed the
“access to a nephrology social worker was important”
 Patients relied on nephrology social workers to assist
them in coping, adjustment, and rehabilitation
 Dialysis patients have ranked a “helpful social
worker” as being more important to them than
nephrologists or nurses
 Dialysis patients also found that social workers were
twice as helpful as nephrologists in aiding the
patient in deciding between hemodialysis and
peritoneal dialysis for treatment.
NEPHROLOGY SOCIAL WORK TASKS
Assessment
Counseling
Education
Crisis Intervention
End-Of-Life Care
Case Management
Rehabilitation
Assistance
Patient Advocacy
ASSESSMENT
 Nephrology social workers conduct an assessment of
patients’ phsychoocial statust to identify their
strengths, needs, and the areas for social work
intervention
 Assessments are completed for every dialysis and
transplant patient and take into account each
patient’s social, psychological, financial, cultural,
and environmental needs
 Social workers also assess transplant donors
COUNSELING AND EDUCATION
 Nephrology social workers provide emotional
support, encouragement, and counseling to patients
and members of their support networks
 ESRD patients may have difficulty adjusting to the
illness and treatment regimes, social workers help
them cope by providing education and counseling to
decrease depression
 One study found that 76% of depressed dialysis
patients indicate that they prefer to seek counseling
from the nephrology social worker rather than pursue
care from an outside mental health practitioner
CRISIS INTERVENTION
 Nephrology social workers provide crisis
interventions in dialysis and transplant units to
patients who may act inappropriately during
hemodialysis, (i.e yelling at staff or other patients,
threatening violence)
 Social workers often effectively mediate conflicts in
dialysis settings
END-OF-LIFE CARE
Social workers provide end-of-life care and
information to ESRD patients and their
families.
Terminally ill ESRD patients and their families
welcomed more emotional support and other
interventions from social workers.
ESRD workgroup for nephrology social workers
entitled “Promoting Excellence in End-Of-Life
Care”
CASE MANAGEMENT
 Social workers provide information to patients and
their families about resources and information that
are unknown to the family
 Renal Social workers routinely provide case
management services, including information,
referrals, and linkages to local, state, and federal
agencies and programs
REHABILITATION ASSISTANCE
 Social workers help patients maximize their
rehabilitation status by assessing barriers to patient
goals of rehabilitation, providing patients with
education and encouragement, and providing case
management with local or state vocational
rehabilitation agencies
 Different roles for social workers related to
rehabilitation are: Enabler/facilitator;
Educator/advocate; and Administrator
TEAM COLLABORATION
 Nephrology social workers collaborate with the
renal team in providing patient care by
participating in quality assurance programs,
team care planning, and training of other health care professionals on the topic of psychosocial
issues
 The 2008 Medicare Conditions for Coverage for
dialysis units mandate that every unit implement
a Quality Assessment and Performance
Improvement (QAPI) program to assess patient
and clinical outcomes
ADVOCACY
 Social workers advocate for their patients within
their clinics as well as with community agencies (see
box 18.4 text)
 Social workers also advocate for patients on a
systems level with various organizations and
governmental agencies
 Renal Social Workers can help patients navigate
complex systems of service provision, and advocate
for patients with community providers that are not
familiar with their special needs
COMMUNITY-LEVEL SOCIAL WORK
 Nephrology social workers are committed to social
reform and influencing policy and programs affecting
renal patients
 Social workers also are employed in macrolevel
services to the ESRD community: i.e clinical
managers, social work directors, social work
coordinators, researchers, and board members of
agencies
PROFESSIONALIZATION OF
NEPHROLOGY SOCIAL WORKERS
 Social workers must often assume responsibility of
clerical tasks (transportation arrangements,
information on medicare/medicaid, etc.) although
these tasks hinder social workers ability to provide
clinical services to patients and their families
 Surveyed social workers spent 38% of their time on
insurance, billing, and clerical tasks versus 25% on
counseling and assessing patients
PROFESSIONALIZATION OF NEPHROLOGY
SOCIAL WORKERS (CONTINUED)
 Positive correlation between job satisfaction and the
amount of time spent in counseling, educating
patients
 Negative correlation between job satisfaction and
time spent with insurance and clerical tasks
 Large caseloads linked to decreased patient
satisfaction & less successful patient rehabilitation
outcomes
COUNCIL OF NEPHROLOGY SOCIAL
WORKERS
 Affiliated with NKF
 Goals
 promote patient, public, professional education
 ensure qualified social workers are in ESRD settings
 Lobbied for inclusion of master’s-level social workers
on renal teams
 Annual training program, publications, newsletter,
set policies and practice
CONCLUSION
 ESRD significant public health concern
 Nephrology social workers proved effective
 Social workers have various practice settings and
work with a variety of clients