Dialysis Patient Needs vs. Social Worker Caseloads

This blog post was made by Beth Witten, MSW, ACSW, LSCSW on April 5, 2018.
Dialysis Patient Needs vs. Social Worker Caseloads

It has been widely reported that depression increases the risk of hospitalization and death for both in-center and home dialysis patients.1 It’s hard to know which comes first--the chicken or the egg, but research looking at factors that contribute to unemployment have found that depressed dialysis patients are less likely to keep their jobs after starting dialysis2 and more likely to say they are unable to work.3

In 1998, the National Kidney Foundation approved the Council of Nephrology Social Workers Position Statement on Social Work Staffing, based on a formula that looked at:

• Patient acuity (psychosocial risk factors)—including age over 60, diabetes, Medicaid or financial problems

• Number of social work tasks mandated by regulation, including assessments, planning care, individual and group counseling, referrals to community agencies and follow-up

• Number of patients the social worker saw in a year.

The recommended ratio turned out to be one social worker for each 75 dialysis patients.

The Council of Nephrology Social Workers (CNSW) did caseload and salary surveys in 2010 and 2014.

• In 2010, with an average caseload of 126 (68% higher than recommended), 76.6% of full-time social workers reported that they didn’t have time to provide psychosocial services to their patients that are mandated under the ESRD Conditions for Coverage.

• In 2014, the average caseload for a full-time dialysis social worker was 116: lower than in 2010, but still 55% higher than the caseload recommended 16 years earlier.

A 2014 article in the Journal of Nephrology Social Work that same year provided evidence that social work interventions have been effective in improving outcomes—but the social work staffing crisis continues for three reasons:

1. The Federal government has not prioritized dialysis staffing as a quality of care issue.

2. Dialysis company investors want labor costs controlled to raise profits.

3. Social workers’ efforts haven’t been enough to change regulations or policies.

Large caseloads often mean that social workers who serve both in-center and home patients spend more time with patients they see more often—and less time with home patients who may not be as forceful at expressing their needs.

Dialysis clinics may think they are doing all they can to provide quality care while maximizing revenue. However, they might see improvement in their patients’ health and quality of life and clinic finances if they reduced social worker caseloads and/or prioritized clinical interventions and limit non-clinical tasks. Why?

• Patient satisfaction with care is higher when social workers’ caseloads are lower, as social workers are more available to help meet patient needs, including providing interventions to treat depression.45 If dialysis social workers are well informed and use their skills and knowledge to reduce depression, it could save dialysis clinics money on lost revenues for hospitalizations and help more working patients keep their jobs.

• In clinics where referrals to vocational rehabilitation are higher, more dialysis patients are employed.6

• When comparing caseloads of 100 or more to lower caseloads, higher caseloads significantly reduced social workers’ rehabilitation interventions.7

The United States Renal Data System hasn’t reported data on revenues from employer plans lately. However, one website touts its ability to reduce employers’ costs for dialysis care, noting that dialysis charges to employer group health plans range from $5,000 to $7,000 per treatment, which fits with what some home dialysis patients have reported on the Home Dialysis Central Facebook discussion group. The site says that standard discounts reduce the amount an insurer pays at most by 45%—leaving employer plans paying $500,000 a year or more for each covered dialysis patient. A company called Specialty Care Management claims to be able to reduce employer group insurance payments to less than $750 per treatment or $12,000 a month (still $144,000 a year).

Compare those figures with Medicare’s base reimbursement of $233 per treatment or $36,348 a year at three treatments a week routinely allowed by Medicare for those with Medicare as their primary payer. It makes good financial sense for dialysis clinics to address depression and help patients stay employed and insured, by:

• Offering evening shifts, in-center nocturnal dialysis, and home dialysis

• Making sure dialysis social workers are knowledgeable and have sufficient time to address patients’ depression and educate and collaborate with patients, vocational rehabilitation counselors, and employers to overcome barriers to patients working.

  1. Lopes AA, Albert JM, Young EW, Satayathum S, Pisoni RL, Andreucci VE, Mapes DL, Mason NA, Fukuhara S, Wikström B, Saito A, Port FK. Screening for depression in hemodialysis patients: associations with diagnosis, treatment, and outcomes in the DOPPS. Kidney Int. 2004 Nov;66(5):2047-53. ↩︎
  2. Kutner NG, Zhang R, Huang Y, Johansen KL. Depressed mood, usual activity level, and continued employment after starting dialysis. Clin J Am Soc Nephrol. 2010 Nov;5(11):2040-5. ↩︎
  3. Kutner NG, Zhang R. Ability to work among patients with ESKD: Relevance of quality care metrics. Healthcare (Basel). 2017 Aug 7;5(3). ↩︎
  4. Johnstone, S. Depression management for hemodialysis patients: Using DOPPS data to further guide nephrology social work intervention. J Nephrol Social Work, 2007 26:18–31. ↩︎
  5. Sledge R, Aebel-Groesch K, McCool M, Johnstone S, Witten B, Contillo M, Hafner J. Part 2. The promise of symptom-targeted intervention to manage depression in dialysis patients: improving mood and quality of life outcomes. Nephrol News Issues. 2011 Jun;25(7):24-8, 30-1. ↩︎
  6. Kutner N, Bowles T, Zhang R, Huang Y, Pastan S. Dialysis facility characteristics and variation in employment rates: a national study. Clin J Am Soc Nephrol. 2008 Jan;3(1):111-6. ↩︎
  7. Callahan, M. B., Moncrief, M., Wittman, J., & Maceda, M. Nephrology social work intervention and the effect of caseload size on patient satisfaction and rehabilitation interventions. J Nephrol Social Work. 1998 18:66–73. ↩︎

Comments

  • Bruce Martin

    Aug 27, 2024 11:57 AM

    The company that I work for and the management structure I work under feels 160 patients is a good number. But in my years in the field, this usually leads to staff burnout, higher chances of mistakes etc. While we may not deal with needles and blood products. Our services provide guidance to patients in their times of need. If a Social Worker is so stretched, the level of care is going to decline. Even for the most seasoned Social Worker. There are some states (California) where it has been mandated by law that the caseloads for Social Workers (and Dieticians) goes no higher than 75. It becomes harder and harder to keep well qualified Social Workers in any capacity if one is not willing to pay well, and not encumber one with an unreasonable case load number. It unfortunately is going to take a negative outcome for anyone to take notice. Which is a sad state of affairs in our for-profit healthcare system.
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  • Jennifer Spencer

    Mar 27, 2024 7:55 PM

    So glad to have stumbled upon this article. I have been a LCSW for 15 years in healthcare and new to dialysis. I've been working at USRenalcare for the past few months and just put in my notice. These concerns validate my reasons to resign. First, I was expected to sign a contract where I was considered "full time" at 30 hours a week. And.. since I'm salary..if the work load requires more hours I am expected to work for free. In my contract, I'm not allowed to have employment outside of US renal care. But that's not the worst of it. I have spent less time being a social worker than being in meetings to retain commercial insurance patients and to do paperwork, applications and most importantly.. insurance. I feel the industry devalues the role of a social worker to focus on keeping the company afloat. Which goes against the CMS guidelines. Sigh...
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  • Lesley Penitusi

    Nov 23, 2022 11:45 PM

    I am wondering if anything has changed with regard to this longstanding issue. I would love to only have 75 patients, but that dream left the barn over 20 years ago when I first started in dialysis. Now, 20 years later, I am still 1 MSW to almost 190 and that's just one clinic. A lot of what I have been going through echoes Mr. Todd's post. The cries to hire more MSWs has always fallen on deaf ears at my facility, because nurses and doctors always take priority. I am burned out, and feel I can no longer be as effective a social workers as I should be because I am only able to tend to patient's concrete needs at this point, with very little to NO time available to focus on their emotional needs.
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    • Beth Witten

      Nov 26, 2022 11:35 PM

      I feel your pain. It is so frustrating to know you could do more if you had more time and support. I believe where you're located there are few MSWs. If the hospital isn't willing/able to hire another MSW, would it consider hiring someone to help you manage tasks that are not specifically mandated under the ESRD regulations? You would need to do patient assessments, KDQOL-36 surveys, care plans, counsel patients/families, and serve on the QAPI team. The case aide could help patients apply for financial aid, answer questions about Medicare and other insurance and choose a Part D plan, identify and refer to community resources, troubleshoot transportation issues, and more. I've seen social service aide positions requiring at least a high school diploma. S/he could be paid less than the salary of an MSW. It's possible the person who would take this job would be interested in working toward a BSW or MSW degree. Perhaps your hospital might be willing to help support that effort based on the patient need and availability of MSWs where you are. Here's the directory of Council on Social Work Education accredited programs. Quite a few offer online classes. https://www.cswe.org/accreditation/directory/
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  • Todd Cohen

    Sep 29, 2018 3:21 AM

    The caseloads and amount of additional work such helping to put patients on binders where FKC owns the product and manipulating patients into signing up for the FKCRx is to the point of being unrealistic, overwhelming, and out of control. I have been a NSW for over 10 years. Last month my census was 161 patients in 3 in-center clinics and one Home Therapy Clinic. I average about 62 hours of work/week, between working in the clinics and at home. I am at the point now where I am physically, psychologically, and emotionally ill. So much so that I have just this last week submitted my resignation for my position with FKC. Requests for help are answered with criticism or a turning of a deaf ear. Patient Care is sacrificed for profit. Yes there are programs in place, "on paper", that show increased care for the patients. But not in actual practice. The tragedy is those assigned to monitor the effectiveness of patient care like CMS and State Surveyors see these "papers" and sign off on what a good job the dialysis clinic is doing, without actually seeing any procedures or technique performed.
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    • Beth Witten

      Sep 29, 2018 11:34 PM

      That a social worker is expected to have that many patients in that many clinics is just plain wrong! I had been told in the past that FKC has a 125:1 ratio of patients per NSW. When NSWs complete paperwork to make it look like the clinic is in compliance with the ESRD regulations, unless the surveyor interviews the NSW (which they’re supposed to do) and the NSW is honest about caseload/time/multiple clinic barriers to fulfilling the requirements under the regulations, the clinic faces no citation and the manager learns he/she can continue these bad practices and save labor costs (perhaps receiving a bonus for doing that). I’m so sorry for your experience and that your patients are losing someone as experienced as you.

      When you leave you can always contact the state survey agency that you’re gone and file a complaint. If the state agency sends surveyors to the clinic to see how the clinic is managing the loss of its NSW, the surveyor may determine there is a deficiency. Clinics have to provide timely SW services to meet patients’ psychosocial needs. If your clinic attempts to do that by making some other NSW cover your clinic in addition to his/her responsibilities during the time before another NSW is hired, the surveyor Identify deficiencies at other clinics too. IMO it is time to report these practices that are limiting how patients’ psychosocial needs are being met.
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  • Susan Witzel-Kreuter

    Apr 12, 2018 7:55 PM

    You are preaching to the choir... those of us in the field for years are well aware of the benefits of our professional time spent with renal patients. We have seen patients thrive with the extra TLC we are trained to offer, helping patients toward positive decisions and effective plans. With the ever increasing demands of paperwork... now computer work, the specific demands of our corporations, the CfC requirements, not to mention the extra time with the neediest of patients, where does the time go? Rather where does it come from? The 1:75 ratio has always been a dream, let's talk about making it a reality for those who follow us!
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  • Delores Anthony

    Apr 06, 2018 3:30 PM

    Very good article. I work in the Tennessee region where as we are told that the fulltime social worker/patient ratio is 120 . I have been reading articles regarding social work/patient ratio in other western/eastern/northern states dialysis clinic to be 80 patients per social worker. I think that is a good ratio for social workers being that we carry the weight of many tasks in our clinics. Certainly, the lower the caseload, the better the outcomes are for the clinic as well as the patients. When you have 120-150 patients, it is nearly impossible to spend enough time with all your patients to address psychosocial problems that cause depression. We are currently utilizing the Empowering Patient Program; however, it does not allow adequate time to establish rapport with patients and then begin to address issues. Okay, will allow someone else to respond.
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    • Elizabeth

      Apr 07, 2018 1:37 PM

      I am a caregiver for my husband in east Tennessee, we do home dialysis, our centers social worker has a huge caseload, due to privacy I don't know her exact load but I am pretty sure she has all home patients for the whole of greater Knoxville, those using fresinous anyway. She comes in for a few minutes each month during our center check in day, the other days she goes out to the in center facilities, that's way too many for one person, it's not just social workers who have a too large caseload, the nurses do too.
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      • b

        Apr 17, 2018 3:01 PM

        I used to be a social worker in the East Tennessee Region with Fresenius, are you with the Home Therapies at Ft. Sanders? They have 2 social workers who split that clinic and then also have one and sometimes 2 other clinics to care for. I know that social worker there if you need assistance I can help?
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      • Beth Witten

        Apr 07, 2018 9:47 PM

        You're right that if the clinic assigns too many patients to the social worker, it's likely that ratios are too high for all staff. Please let the administrator or nurse manager who's in charge know that you appreciate the staff they have, but wish they had more time to spend with you and the other patients. Staff may have tried to advocate for better staffing in the past. Maybe it would make a difference if that suggestion was coming from patients.
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        • B

          Apr 17, 2018 3:03 PM

          You will need to let the Director of Operations know, they are the ones who staff the clinics. The clinic managers have nothing to do with the social workers staffing schedule
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    • Beth Witten

      Apr 06, 2018 8:55 PM

      When I worked as a nephrology social worker in dialysis, I met with new patients as soon as possible after they were admitted. I used the 1-2 hours I spent conducting each psychosocial assessment to not only learn about them, to provide education on key topics, to help them understand my role, and to establish rapport that is so important in a positive working relationship. Today with caseloads as large as they are, sadly I suspect it's a rare social worker who has a 2 hour block of time to spend with one patient. If patients knew what they were missing, they could just be the social worker's strongest ally.
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  • Jim Roach

    Apr 06, 2018 1:59 PM

    Excellent article all the way through. Something I have not heard address regarding Social Work/counseling is the time involved with any given patient. Patients don't present to Social Workers as they do with a doctor or nurse.

    Social Workers have to mine for the symptoms (not always but most of the time) and then work at running down the cause ( possibly all the while having to address patient resistance) of the symptoms and most times convince the patient to let the Social Worker help the patient.

    First the Social Worker has to develop rapport with patient, then develop a working relationship with the patient and then develop trust with the patient. Because we all know, if there's no trust there's no rapport, no relationship being developed and therefore, no possible chance of trust being developed and bottom line is the patient is not receiving the necessary help. There is much more that has to be accomplished before the Social Worker can legitimately address any issues with any given patient. And there is no cookie cutter approach that works with every patient. There is so much more but I will stop. Just my two cents for what it's worth.
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    • Beth Witten

      Apr 06, 2018 2:30 PM

      You are so right! It takes time to establish a trusting relationship with a new patient that we hope will continue as long as the patient and social worker work together. There are brief interventions that social workers can use to address specific patient needs, success of those interventions relies on rapport and that trusting relationship.
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  • Cate Wilk

    Apr 06, 2018 12:59 PM

    Very good! Just talking about the insurance rates on a FB site for SWs and why unions are having a hard time with the AKF HIPP maintaining commercial coverage for patients that could get Medicare. Very split reactions on that topic. As far as staffing; it's tough keeping up with regulation expectations when you have a home program and an ICH program that are both super busy and pulling you back and forth. Neither area is getting the best service from SW at the current high ratios.
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    • Beth Witten

      Apr 06, 2018 8:44 PM

      At the NKF Spring Clinical Meetings there will be a presentation on a recent survey of social worker caseloads and salaries. The findings will be published in the next issue of the Journal of Nephrology Social Workers. I'm looking forward to seeing what changes have taken place over the years. These data are reported for 2007, 2010, and 2014 here - https://www.kidney.org/professionals/CNSW/salarySurvey08
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