Helping Dialysis Patients Work: Home Dialysis Is Work-Friendly
Do you have patients who start dialysis with a job and have a goal to keep the job, their income and standard of living, individual or family health benefits, maintain their sense of self-worth, and keep work friendships? You may also have patients who worked previously, but are now getting Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) and having a hard time making ends meet. They may be looking for ways to make money. This blog focuses on helping patients keep the job they have when they start dialysis.
Patients on in-center dialysis can work, but in-center HD challenges patients physically and mentally due to feeling “washed out.” Few dialysis clinics offer in-center nocturnal or evening shifts starting after 5 p.m., which is a significant challenge to working on in-center HD. Several factors influence whether an incident dialysis patient is working, including modality.1 USRDS data on incident patients shows how many were working full or part-time in 2023.2
| Employment status | In-center HD | PD | Home HD |
|---|---|---|---|
| Full-time | 8.5% | 24% | 14.9% |
| Part-time | 2.6% | 3.9% | 3.5% |
Evaluation of Patient’s Work Status and Goal(s)
On April 15, 2008, the ESRD Conditions for Coverage for ESRD Facilities3 was published with an implementation date of October 15, 2008. CMS sought input from key members of the renal community to write interpretive guidance (IG)4 to help those surveying dialysis clinics know what and how to monitor compliance with the regulations.
At 42 CFR §494.80 is the Condition: Patient assessment. It states at (a)(7) Evaluation of psychosocial needs by a social worker. The interpretive guidance (IG) has a bullet list of areas for this assessment that includes “Educational and employment status, concerns, and goals.” Although the social worker is intended to take the lead in this assessment, “Other members of the IDT may contribute to portions of the comprehensive assessment which correlate with the psychosocial evaluation (e.g., patient preferences for modality and self-care at V512, evaluation for transplant referral at V513, family/support systems at V514, and evaluation for referral to rehabilitation services at V515).”
It states, “The facility’s interdisciplinary team, consists of, at a minimum, the patient or the patient’s designee (if the patient chooses), a registered nurse, a physician treating the patient for ESRD, a social worker, and a dietitian. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment of his or her needs. The comprehensive assessment must be used to develop the patient’s treatment plan and expectations for care.” Per the IG, dialysis clinics should encourage patients to attend, have a system for IDT members to develop an “integrated, congruent” plan of care with any IDT member, and allow any IDT member to participate remotely.
CMS suggested that the American Nephrology Nurses Association (ANNA) and the National Kidney Foundation develop guidance and resources to help clinics with the assessment. Heeding CMS’ advice, the Council of Nephrology Social Workers (CNSW) developed a Comprehensive Multidisciplinary Patient Assessment (CMPA) tool (below) to help social workers working in dialysis conduct their patient assessment. Vocational status is one of the assessment areas. CMS does not mandate what tool clinics should use to assess dialysis patients and dialysis clinics then and now have the option to use or modify the CMPA or to develop their own method to assess patients as long as it includes at minimum all the criteria listed in the CfC, the assessment is performed at the correct time and frequency described in the CfC, and the team uses their combined assessments to plan care. Below is the section of the CNSW tool on rehabilitation.
Comprehensive Multidisciplinary Patient Assessment Example Questions5
SB6. What is the patient’s employment status?
Prior employment If initial assessment, use 6 months prior to starting dialysis. If reassessment, use status at last assessment |
Current employment |
|---|---|
Employed full-time Employed part-time Retired Medical leave of absence Unemployed (by choice) Unemployed (looking for work) Unemployed (disabled) |
Employed full-time Employed part-time Retired Medical leave of absence Unemployed (by choice) Unemployed (looking for work) Unemployed (disabled) |
SB6a. If not working, what is the patient’s vocational rehabilitation (VR) status?
Already working with VR agency
Patient referred to VR
Patient has expressed interest in VR, but has not followed up
Patient not interested
Patient not eligible
Patient looking for employment on own
SB7. Is the patient’s dialysis a barrier to positive vocational outcomes?
Yes No
SB7a. If yes, what barriers does the patient report that prevents him or her from working or attending school? (Examples: missing workdays, not enough energy to perform job, not able to attend school, etc.)
Under the Condition: Patient plan of care at 42 CFR §494.90(a)(6) Psychosocial status, it states:
“The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals 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 chosen by the social worker, at regular intervals, or more frequently on an as-needed basis.” The IG states, “The social worker is expected to assist patients in achieving their psychosocial goals. Counseling services to patients and their families should be directed at helping the patient and family cope with kidney failure and dialysis, follow the treatment plan, and achieve the patient’s goals for rehabilitation.” Further, it suggests clinics use the KDQOL-36TM with adult patients (or an age appropriate survey for pediatric patients) to assess a patient’s mental and physical status. One resource for this is the non-profit Medical Education Institute’s (MEI) KDQOL Complete scoring tool, reports, and resources. In March, a Home Dialysis Central blog shared information about scoring and use of that survey.6
The CfC at §494.90(a)(8) Rehabilitation status, it states:
“The interdisciplinary team must assist the patient in achieving and sustaining an appropriate level of productive activity, as desired by the patient, including the educational needs of pediatric patients (patients under the age of 18 years), and make rehabilitation and vocational rehabilitation referrals as appropriate.” The IG states, “The goals for the plan of care in this area must be individualized for the patient (e.g., return to a former occupation, attain an educational certificate or diploma, return to normal activities within a household, etc.) and reflect the patient's preferences. The social worker should be aware of the availability of community referral options for physical and vocational rehabilitation services for all patients, and educational resources for pediatric patients, if applicable for this facility. The IDT should have a plan and procedure for making referrals for rehabilitation. The IDT must provide and document assistance (e.g., education, encouragement) and referrals, if indicated, which were aimed at enabling patients to maintain or return to their desired level of functioning at work, school, home and in their community.”
Dialysis Patient Treatment Choice and Employment
As can be seen from the USRDS data previously reported, the treatment a patient chooses—or the doctor recommends—can make a difference in whether a dialysis patient keeps his/her job when starting dialysis. To help clinics determine what treatment option(s) fits best with the patient’s values—not what anyone else thinks the patient should choose—MEI developed My Kidney Life Plan. This evidence-based decision aid can help dialysis clinics comply with the CfC at §494.90(a)(7) Modality (i) Home Dialysis, which requires dialysis clinics to plan care for home dialysis or explain why the patient is not a candidate. It asks patients to choose the top 3 things they value most. Then it provides stars for how well each option fits their values. If a patient chooses the lifestyle value “I want to work or go to school,” they may find that PD, home HD or transplant fits well, since those are more work-friendly options than in-center dialysis. Knowing this could help the team plan to refer the patient to the clinic’s home training nurse or to a clinic that offers home dialysis if their clinic doesn’t. The IG states, “Patient records must demonstrate that each patient was informed about all available dialysis modalities and locations for home dialysis training if that service is not available at this facility. If the patient expressed interest in home dialysis and was determined to be a suitable candidate, the plan of care should list use of this modality as a goal and identify ways to achieve it (e.g., timeline for training in home dialysis at current facility, referral to a facility certified for home training and support). If the patient declined or was determined not suitable for home dialysis, the IDT must document their rationale for this decision.”
Resources to Help Staff Help Patients Who Want to Work on Dialysis
How can clinics and dialysis staff help patients work if they want to and are physically and mentally able to work? Patients considering applying for disability need to understand that even Cadillac disability plans from a job do not fully replace work income. Social Security has a calculator that shows what Social Security may pay if someone becomes disabled. Many patients find this to be insufficient to cover their expenses leading to anxiety and depression.
There are several resources to help patients and staff learn more about working on dialysis.
DaVita – Stay Employed, Stay Healthy
Fresenius – Tips for Working While on Dialysis
Home Dialysis Central – Keeping Your Job When You Need Dialysis
Medical Education Institute – Kidney Failure and Your Work Life
My Kidney Life Plan (value) – “I Want to Work or Go to School”
The National Kidney Foundation – Working with Kidney Disease: Rehabilitation and Employment
Renal Support Network podcast – Working on Dialysis
The U.S. Renal Care website – Working While on Dialysis
Clinics can Performing a Self-Assessment of Their Vocational Rehabilitation Efforts
The Life Options program developed the Unit Self-Assessment Tool (USAT) to help dialysis clinics evaluate what they were doing to meet patients’ needs and goals in five areas: Encouragement, Education, Exercise, Employment and Evaluation. The Exemplary Practices in Renal Rehabilitation contest encouraged dialysis clinics to submit applications describing what their clinic was doing to promote rehabilitation in one or more areas. See the employment section of the USAT at the end.
From the Life Options Unit Self-Assessment Tool7
USAT Employment Criteria
BASIC REHABILITATION INTERVENTIONS: Score 1 point for each “yes” answer
EM-1 ____ Do you have a centrally located bulletin board featuring employed/rehabilitated patients?
EM-2 ____ Do you inform patients about choices of treatment modalities to accommodate their work and life interests?
EM-3 ____ Do you provide any kind of information about ESRD to your patients’ employers?
EM-4 ____ Do you provide information to patients and their employers about accommodations that must be made in the workplace for ESRD patients?
EM-5 ____ Do you provide information for families about patients’ potential to continue working and the benefits of working?
EM-6 ____ Do you regularly conduct “informal” screening for employment status or potential?
EM-7 ____ Does your unit have/provide any other employment-related activities that are not covered above?
INTERMEDIATE REHABILITATION INTERVENTIONS: Score 1 point for each “yes” answer
EM-8 ____ Do you have an ongoing relationship with the VR agency to facilitate patients’ retraining or job placement?
EM-9 ____ Do you provide any job-seeking skills training, such as resume writing, interviewing techniques, or “dress for success” information?
EM-10____ Does your unit automatically refer all working-age patients to VR?
EM-11____ Do you have any in-center employment support groups?
EM-12____ Do you sponsor or provide for any direct staff communications with patients’ employers?
EM-13____ Do you have any relationship with a “temporary employment” service for potential training or jobs?
EM-14____ Do you support/sponsor regular interactive sessions among staff and patients about the importance of employment?
ADVANCED REHABILITATION INTERVENTIONS: Score 1 point for each “yes” answer
EM-15____ Do you conduct formal screening of patients for employment status/potential?
EM-16____ Do you have any mechanism or program to connect patients with jobs?
EM-17____ Do you provide any early interventions (predialysis or within first 6 weeks) to help patients keep their jobs?
EM-18____ Do you provide for individualized flexible dialysis scheduling (i.e., treatments beginning after 5 pm; weekend dialysis; self-care opportunities; separate shift for working patients; and/or priority scheduling for working patients)?
EM-19____ Do you track the outcomes or results of your employment-related initiatives?
EM-20____ Do you track the costs associated with your employment-related activities and program?
__________ SUBTOTAL (20 possible)
Conclusion
Helping patients keep their jobs and their lifestyle can go a long way to helping them have better physical and mental outcomes. Doing what a clinic can to help dialysis patients keep their jobs can help clinics’ financial stability since job-based health plans pay much more than Medicare during the 30-month Medicare secondary payer period. Dialysis clinics that have CMS approval for home dialysis might consider starting an in-center self-care program to build patient knowledge and confidence as a step to home dialysis and get paid for training. Clinics without current CMS approval for home dialysis might consider adding an evening or nocturnal shift or starting a home dialysis program. See Home Dialysis Central’s Start a Home Dialysis Program. Finally, the revenue from helping more patients work could allow a clinic to increase staffing of patient educators, social workers, and home training nurses—A win-win for all.
Muehrer RJ, Schatell D, Witten B, Gangnon R, Becker BN, Hofmann RM. Factors affecting employment at initiation of dialysis. Clin J Am Soc Nephrol. 2011 Mar;6(3):489-96.↩︎
United States Renal Data System. 2025 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2025. https://usrds-adr.niddk.nih.gov/2025/end-stage-renal-disease/3-home-dialysis↩︎
Department of Health and Human Services, Centers for Medicare & Medicaid Services. Medicare & Medicaid Programs Conditions for Coverage for End-Stage Renal Disease Facilities. Fed. Reg. Vol 73, No. 73, April 15, 2008. https://www.govinfo.gov/content/pkg/FR-2008-04-15/pdf/08-1102.pdf↩︎
Centers for Medicare & Medicaid Services. ESRD Surveyor Training Interpretive Guidance, Final Version 1.1, October 3, 2008. https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/esrdpgmguidance.pdf↩︎
Council of Nephrology Social Workers. Comprehensive Multidisciplinary Patient Assessment Sample Questions. https://www.kidney.org/sites/default/files/v29_a3.pdf↩︎
Witten B, Honer K. How Are You Scoring and Using the KDQOL-36TM to Plan Care? March 19, 2026. https://homedialysis.org/news-and-research/blog/688-how-are-you-scoring-and-using-the-kdqol-36-to-plan-care↩︎
Life Options Rehabilitation Advisory Council. Unit Self-Assessment Manual for Renal Rehabilitation: A Guide to the Use and Interpretation of the Life Options Unit Self-Assessment Tool for Renal Rehabilitation. https://lifeoptions.org/assets/pdfs/evaluation.pdf↩︎
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