Social Work Services to Meet Home Patients’ Psychosocial Needs

This blog post was made by Beth Witten, MSW, ACSW, LSCSW on October 22, 2018.
Social Work Services to Meet Home Patients’ Psychosocial Needs

What the Regulations Say

The ESRD Conditions for Coverage (CfC) under the Condition for Patient Assessment (42 CFR 494.80), mandates that the interdisciplinary team (IDT), including the qualified social worker, perform patient assessments at regular intervals. Although the social worker’s input can be helpful to the team in assessing and planning care in other clinical areas, areas where the social worker can and should take a lead role include assessments of the patients’:

  • Psychosocial needs, family and other support systems, and care planning to enhance the patient’s psychosocial status

  • Abilities, interests, preferences and goals, including desired level of participation in dialysis care, modality and setting, and expectations for outcomes and planning care for the patient’s preferred modality and setting as appropriate;

  • Current physical activity level and need for physical and vocational rehabilitation and planning care to achieve the patient’s goals for rehabilitation.

Social workers’ assessments can be invaluable for home dialysis and transplantation. The Condition for Patient Plan of Care (42 CFR 494.90) requires the IDT to develop a plan of care based on the most recent assessment. The social worker is responsible for providing “counseling services and referral for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool…” Under the Condition for Governance (42 CFR 494.180), the dialysis clinic’s governing body through the CEO or administrator is required to have an “adequate number of qualified and trained staff. The registered nurse, social worker and dietitian members of the interdisciplinary team are available to meet patient clinical needs.”1 The Condition for Care at Home (42 CFR 494.100) addresses requirements specifically for home dialysis patients, and the Conditions and Standards in the ESRD CfC apply to home patients as well as those who dialyze in-center.

What the Regulations Mean for Social Workers and Home Dialysis Patients

In-center patients have more opportunities for face-to-face contact with their social worker because they come to the dialysis clinic where the social worker has an office, three times a week in most cases. Many social workers serve patients at more than one clinic, so an in-center patient may only have in-person access to the social worker certain days and certain hours. A home patient’s face-to-face contact with the social worker is even less, since home patients may only come to the clinic once or twice a month, sometimes less often. If a social worker is at another clinic or away on sick leave or vacation, s/he may not see the patient for an extended period of time.

Social Workers: Stay in Touch with Your Home Patients

People often assume that home dialysis patients are better educated and function at a higher level than in-center patients, which may lead them to believe home patients need less contact with social workers and fewer psychosocial services. In truth, home dialysis patients can be very independent and able to do dialysis with little or no help—or can be totally dependent on others to meet their needs while living in their own homes or in a nursing home. They may have psychosocial issues that need to be addressed, such as:

  • Coping with kidney failure and dialysis that can adversely affect such things as mood, appetite, strength, energy, endurance, work, activities, relationships, sexual interest and functioning, fertility

  • Eating the right foods and fluids to stay as healthy as possible

  • Affording the cost of prescribed drugs

  • Timing of clinic visits, when the scheduled time may conflict with work or life and transportation may be unreliable

  • Balancing asking for help at times—but worrying about being a burden

  • Fearing disability, debilitation, and death

In addition, home patients may have instrumental needs related to:

  • Learning to perform dialysis with or without help from a care partner

  • Needing to have equipment and supplies delivered to their home on the delivery person’s schedule, which may conflict with work or other activities

  • Finding a place to store supplies in their home and arranging a dialysis space

  • Needing a family member or friend to volunteer as a care partner if one is needed

  • Paying a helper to do dialysis if he/she can’t do it alone

  • Having close family members who need support as they experience the patient’s health challenges with their own fears for the future

Meeting the Needs of Home Dialysis Patients

You may need to help your patients understand what a nephrology social worker can do. Many people have skewed views of social work from the media. Some may believe that social workers help only poor people. If they’re not poor, they may not understand that the dialysis social worker not only knows about community resources but also has skills to help the patient identify and address problems like the ones listed above.

With home patients, since face-to-face contact is likely to be limited, dialysis management needs to prioritize scheduling the social worker to be at the dialysis clinic on home patient clinic days. Being present during those times allows the social worker to meet individually with each patient to briefly catch up on how dialysis is going and how the patient is coping in other aspects of the his/her life. Between clinic visits, social workers can stay on top of patient concerns by keeping in touch by phone or secure email. Many times social workers do assessments and provide counseling chairside for in-center patients. For home patients, options may include:

  • Using a private space in the dialysis clinic

  • Providing counseling and referral to other services by phone

  • Making a home visit to assess how well the patient is doing

With home patients who may have limited time in the dialysis clinic, thinking outside the box is key.


Home dialysis patients sometimes appear more physically and emotionally stable than they are. Dialysis social workers need to make sure that responsibilities for other patients and clinics still allow them sufficient time to meet the psychosocial needs of their home patients. If those patients’ needs are met, they are likely to do well, to live full and productive lives, and to remain on home dialysis for decades—or until they get that call for a transplant, if desired.

  1. Centers for Medicare & Medicaid Services. Conditions for Coverage for End-Stage Renal Disease Facilities, Final Rule. 73 FR 20369, April 15, 2008.


  • Beth Witten

    Aug 14, 2019 5:16 PM

    Thank you for sharing these tips for home visits. Home visits are a great way for patients to get to know you and to get to know your home patients better. I'm really glad you and other social workers have this opportunity. Thank you for all you do to help your patients live full lives!
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  • Cara Snyder

    Aug 14, 2019 5:03 PM

    I like your blog post, Beth. Thank you for sharing! When I do home visits I try to view it as an opportunity to build rapport since we have very limited face time with our home patients. I always ask how they are sleeping. The answers will give you insight on patient adjustment to home therapy, anxiety level, sx of depression, whether the machine sounds are disruption to them or their partner, etc. I also ask “what are you doing for fun”. Similarly, the answers open the door to further dialogue like relationships, activity level, barriers to feelings of wellness, etc. Look around and observe family photos (or the lack thereof), evidence if spirituality to get a clearer idea of the patient support system. If the patient has a partner I often ask them to take a walk or show me the garden, etc, so I can get some one on one time to evaluate how they are managing and what their feelings are regarding the patient adjustment. I love home visits and all they provide for assessment and relationship building.
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