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.
- 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. ↩︎
- 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. ↩︎
- Kutner NG, Zhang R. Ability to work among patients with ESKD: Relevance of quality care metrics. Healthcare (Basel). 2017 Aug 7;5(3). ↩︎
- 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. ↩︎
- 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. ↩︎
- 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. ↩︎
- 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. ↩︎