Dialysis Social Work During a Pandemic: Caring for Patients Safely

How much do you know about your social worker’s education, training, and mandated responsibilities? This blog is intended help dialysis clinic staff and managers know how your social worker, if given sufficient time and support, can help achieve patient and clinic goals using his/her education and skills.

The ESRD Conditions for Coverage (CFC) and a Social Worker’s Qualifications

The CFC require dialysis clinics to have a “qualified social worker” to meet the psychosocial needs of in-center and home dialysis patients treated at the dialysis clinic. Each dialysis social worker must have a master’s degree in social work (MSW) with specialization in clinical social work from a graduate program accredited by the Council on Social Work Education (CSWE).

Graduate programs include at least 900 hours of field practice so even a new MSW graduate has significant experience providing psychosocial care. A new graduate will need to learn about kidney disease, treatment options, resources, and how to help patients cope with this chronic life-altering illness. If you can hire a social worker with dialysis experience, the learning curve will be less. The Council of Nephrology Social Workers has great member resources for new and experienced social workers, including the CNSW listserv where nephrology social workers can share resources, get answers to questions, and get and give support.

The ESRD CFC states, “All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed.” The Association of Social Work Boards (ASWB) has a database of state social work regulations. Social workers need to know how their license defines the scope of their practice, so they meet—but do not exceed—what their license/certificate allows.

The ESRD regulations require social workers to do counseling “to assist the patient in achieving and sustaining an appropriate psychosocial status.” Social workers must have a license that allows them to provide counseling. In some states, this is the basic license for an MSW. In others, a clinical social work license is required for counseling—which requires a certain amount of supervised experience as an MSW. In addition, CMS requires dialysis clinics to screen patients for depression (with a few exceptions). A social worker can do this without a clinical license, and may be able to do interventions to reduce depression. However, only those with a clinical social work license can diagnose and treat depression in most states.

The CFC and the Social Worker’s Essential Responsibilities

As an essential member of the interdisciplinary team (IDT), the social worker contributes to the comprehensive assessment and plan of care by evaluating patients’ psychosocial needs and taking action when problems are identified. According to the ESRD Interpretive Guidance, the social worker should assess the patient’s:

• Cognitive status

• Concerns and goals

• Educational and employment status

• Coping with kidney disease

• Living situation and support system

• Financial status and ability to meet basic needs

• Programs that can help

• Ability to follow the treatment prescription

• History of mental illness or substance abuse

• Need for counseling

In addition, the social worker and other team members assess the patient’s abilities, interests, preferences, desired level of participation in care, preferred treatment option and setting, and need for physical rehabilitation.

Based on the assessment of vocational status and goals, the social worker can educate the patient about keeping a job with kidney disease, and work incentive programs, and can refer the patient to public and private vocational rehabilitation. Social workers are very busy trying to meet the regulatory mandate when many cover multiple clinics and have high caseloads of 125 or more. Currently CMS COVID-19 waivers allow some flexibility in meeting timelines for assessments and plans of care. However, the waiver for ESRD clinics does not provide flexibility for the social worker who is charged with meeting patients’ needs.

Home Patients’ Needs

Some staff may believe home dialysis patients are so independent that they need little time and attention. Social workers working with home patients must assure that patients’ day-to-day needs are met for shelter and utilities, nutritious food, medications, medical-related transportation, and paying for all of it. Home patients are trying to cope with having a chronic illness and doing dialysis the prescribed time and frequency. Some home patients—with or without a care partner—may have added stress because they are seen less often and have limited supervision, but others are fine with that. Stresses patients have mentioned include:

• What symptoms should I report and to whom?

• Who do I contact for an HD or PD access problem?

• Who do I contact when a machine isn’t working right?

• What should I do when my supplies don’t arrive on time?

• How can I advocate for telehealth visits instead of in-person ones to avoid COVID-19?

• How can I get heavy supplies to my dialysis room when a delivery person can’t come in?

• How can I stay safe if a clinic visit is required for labs, medications, or other problems?

Dialysis patients are at higher risk for severe complications of COVID-19 because they have kidney disease. Many are also are older or have diabetes and/or high blood pressure. Home patients need a social worker who has time to talk with them, answer their questions, share resources, and offer emotional support.

Tasks that Could be Assigned to Other Staff During this Pandemic—and Afterward

Even prior to this pandemic, social workers were often asked to do multiple clerical tasks that an administrative assistant could do when trained and supervised by a social worker, like making transient dialysis, transportation, or insurance arrangements, and filling out financial assistance applications. These tasks take valuable time away from the social worker’s clinical responsibilities. With COVID-19, a number of large dialysis organizations are using social workers to screen patients for COVID-19 before they enter the in-center or home training area. Every minute that a social worker performs this function is a minute that a social worker is not addressing patients’ psychosocial needs. A social worker can be trained to perform this medical function. However, medical screening is not in a social worker’s scope of practice as defined by their license, so performing this task could put a social worker’s finances and license at risk if a screened patient becomes ill, infects someone else and sues the clinic, and/or files a complaint with the state licensing board.

One social worker wrote, “I don't think any SWs should be doing those (screening) assessments. They are clinical in nature and are out of our scope of practice—just like nurses can't write prescriptions. I personally have not been doing them, but many others are. I hope that the policies change and state that licensed social workers should not be doing these tasks.”

Telehealth Can Help Social Workers Work at Home

The CMS’ ESRD Provider Telehealth and Telemedicine Tool Kit describes the 1135 waiver, including the policy and how to set up and implement telehealth, state statute guidance, telehealth technical assistance, vendor selection, telehealth articles, and patient and community resources.

The tool kit states “The Office of Civil Rights will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communication techniques such as FaceTime or Skype, during the COVID-19 public health emergency.”Medicare providers—including clinical social workers in private practice—can bill Medicare for telehealth visits. (NOTE: Dialysis social workers’ services are covered under the prospective payment rate and are not separately billable.)

Concerned about how social workers can participate in Plan of Care (POC) and Quality Assessment and Performance Improvement (QAPI) meetings? The ESRD CFC allows IDT members to participate in these remotely. The Interpretive Guidance states that consultation between the IDT and home patients can be in-person, by telephone or email. And, the CMS 1135 waiver now allows the social worker and other staff to consult with patients via other communication techniques.

I am a strong proponent of dialysis clinics allowing social workers to work from home, especially those at greater risk of COVID-19 complications. CDC guidelines describe who is higher risk, such as those 65+, those with diabetes, high blood pressure, heart disease, lung disease/moderate to severe asthma, are immunocompromised, or obese (BMI 40 or higher). The CDC has suggestions for those at risk here. Some dialysis social workers may be pregnant or breastfeeding. The CDC has guidelines for them too.

Considering the risks for some social workers, I posted on the CNSW Listserv some arguments for social workers to work at home:

• The president’s order and communities are encouraging those who can work from home to do so.

• The limited supply of PPE should be designated for those who truly need it for direct patient care responsibilities.

• The ESRD CFC:

  • Allows communication with patients by phone and email (the order allows use of other telehealth tools that are not HIPAA-compliant)

  • Allows any IDT member to participate in POC and QAPI meetings by phone

Some social workers responded to my post saying that being at the clinic in this emergency when it’s “all hands on deck” helps them feel like a valued team player. Others who face the same risks as their patients due to age or pre-existing health conditions requested to work from home. Some comments included:

• “I am forced to work from the clinic, as essential personnel. I have been doing everything from my office, with little contact other than on the phone. I could be home safely with my family and doing the same tasks. Mind you, I am in my 60s ready to retire soon. I want to be here for my patients, but I have a family and life to worry about.”

• “Our dialysis staff are all wearing face shields, masks, etc., and it is extremely difficult trying to talk with patients in the unit—it is difficult to hear, and I found myself just getting closer trying to have them hear me and me hear them. My patients have been very receptive of me calling them in lieu of being in the unit. They want us to be safe as much as we want them to be safe. I think our conversations have been greater quality on the phone also, as the ease of communication is so much better.”

• “I have two conditions which make me a higher risk of getting COVID. A mask is great for keeping someone from spreading but does not keep the person from getting.”

• “We have to wear PPE including a mask when on the floor or talking to home patients when they are in clinic. Patients are wearing masks too, which is making communication more difficult. We can call patients from the office or from home, and talk with them about issues, etc. Working from home will also save on PPE.”

Some social workers said their clinics allowed those at higher risk of serious complications from COVID-19 to work at home. Two social workers who are over 65 told me:

• “It took me a month to convince them. I took 2 weeks of PTO, then learned from (my company) that they offer up to 60 days of unpaid leave that will hold your job. Then they just let me take my work computer and printer home. So, I’ve been working from home since 4-13. It has worked very well so far. I do it at my “home desk” so actually have more room to review computer print outs and catch errors or reason for questions. It is more private than on the treatment floor. I have used an app called “Side line” which allows me to use my cell phone but shows up as the “Side” number instead of my own number, which makes me more comfortable with using my phone. I can extend my work hours into the evening if that is when I have to reach a patient.”

• My clinic is in a hot spot. I’ve been sick for weeks with symptoms of COVID-19, but the test was negative. My clinic manager is allowing me to work from home. I talk with patients by phone and they talk about things they hadn’t talked about on the floor. The conversations are easier to hear without the clinic background noise. I’ve helped patients with concrete problems too. My manager says I’m more productive than some social workers who work onsite.

Some social workers’ reports of denials of work-at-home requests are beyond my comprehension. One who was quarantined for pneumonia awaiting COVID-19 testing was told s/he could not work from home. Another social worker with a heart transplant was denied work at home. And a social worker reported an ex had threatened to seek custody of their immunocompromised child because the social worker’s work in the clinic placed their child at risk.

Requests for Work at Home

I have been told by leadership in the two largest dialysis organizations that requests for work-at-home are reviewed and considered on a case-by-case basis. Sometimes we do a better job of advocating for our patients than we do advocating for ourselves. If your health and life could be at risk, now is the time to speak up. I recommend that if you are in a high-risk group:

• Get a doctor’s letter that describes why you are at higher risk.

• Share the letter with the lead social worker (if one exists), clinic manager, clinic medical director, and regional director (if one exists).

• If your request is denied, send it up the chain of command to the person overseeing clinical services up to and including the chief medical officer.

Conclusion

Social workers must perform mandated tasks to help patients and to avoid clinic citation, even when there is flexibility in timelines. Assigning non-clinical tasks that don’t require the master’s prepared social worker’s knowledge and skills to another staff member allows the social worker more time to focus on those clinical responsibilities with patients. Some social workers may want to work in the clinic and are not at increased risk. However, social workers who are at higher risk should know whom to direct a request and medical letter to.

Dialysis clinics should look to guidelines and recommendations from the CDC, state health department, and other reliable sources. Social workers should not have to take PTO if they can meet patients’ needs from home. It is possible to provide secure access to medical records so the social worker can document communications and interventions. If a doctor can use telehealth to assess patients, make healthcare decisions, share them with the patient virtually, and document those visits and interventions in medical records, social workers especially those at high risk themselves or responsible for caring for high risk family members should be allowed do this, too.