When social workers earn their Master’s degree, at least one thing is very clear: they have learned about the interplay of bio-psychosocial forces active in the life of every human being, and that these forces shape behavior.

Nephrology social workers see that dynamic in their patients with kidney failure each and every day. As they enter the world of integrated care, where they are invited into roles to improve quality while containing cost, it is no surprise that the master’s-level social worker feels right at home. From their seat at the integrated care table, they can help reach these goals by tailoring team care to the inner world of the patients being treated.

ACOs and renal disease

Integrated care has been a long time coming for the renal disease industry. Accountable care organizations, which spring from the goals of the Medicare Shared Savings Programs mandated by the Patient Protection and Affordable Care Act of 2010, bring together voluntary groups of hospitals, physicians, and health care teams that understand how Medicare and Medicaid beneficiaries with ESRD have significant and costly care needs. Medicare beneficiaries with ESRD constituted >1% of the Medicare population but consume a disproportionate 6.7% of the total Medicare budget, excluding Medicare Part D. 1 Dialysis patients continue to experience frequent, lengthy, and costly hospitalizations. Such poor outcomes may be attributed in large part to high patient acuity and complexity and a fragmented care delivery system. 2 The complex health needs of the ESRD patient often require beneficiaries to visit multiple providers and follow numerous care plans, which can be challenging for beneficiaries when care is not well coordinated.

Through enhanced care coordination, these beneficiaries can have a more person-centered care experience, which will ultimately improve health outcomes and beneficiary satisfaction. 3 If dialysis providers can contribute new and successful ways to reduce the cost of care under these new types of care models and other CMS initiatives––especially in the area of hospitalizations––they can receive a share of the cost savings to keep their business viable. Enter: Nephrology social workers with a mission to engage in onsite behavioral health care interventions that enhance patient adherence and adaptation to chronic illness.

Targeting high risks

As this new era of care advances, social work services that directly provide the coaching and counseling services to help patients manage the demands of treatment are under the spotlight. At Fresenius Medical Care, the Social Work Intensive Program (SWI), launched across the country in 2012 to serve patients at higher risk of hospitalization, is positioned strategically now in the Integrated Care Division. This social work program offers additional behavioral health tools when standard MSW interventions do not succeed in ameliorating psychosocial and quality of life barriers. The program has received the Modern Healthcare Spirit of Excellence Award for its ability to reduce the cost of care by improving patient adherence behavior. 4 Data presented at the American Society of Nephrology’s annual meeting in November 2014 confirmed the role of the program’s quality of life, depression, sleep and stress outcomes in reducing missed treatments, and fluid-related hospitalizations. 5-7

Social work leaders are expanding their oversight of social work roles with patients at high risk of hospitalization and a new Director of Social Work in Integrated Care position has been created to drive the value of these behavioral health programs into a cost-sensitive future. “Nephrology social workers are uniquely equipped to assist the interdisciplinary team (IDT) in identifying underlying root causes of patient non treatment adherence as well as other psychosocial barriers that can be very complex and lead to frequent patient hospitalizations,” says Greg Garza, vice president of Integrated Care for Fresenius Health Partners. “Utilizing their full skill set of our social workers, we are able to find opportunities to improve their quality of life while reducing the overall cost of care to the delivery system.”

Social work programs such as the SWI launch social workers toward early screening of risk criteria. Low quality of life scores, non-adherent behavior, interpersonal stress and depressive symptoms are among the psychosocial variables that are known contributors to mortality and hospitalization. 8-16 Early social work screening allows patients at higher psychosocial risk to be triaged into treatment programs as soon as they are identified. 14

Patient engagement has been exceptionally strong in this type of social work model, compared to models of the past 20 years where dialysis patients were referred to mental health providers not situated on the dialysis team. While only 36% of patients are willing to see an outside mental health provider and even fewer follow up on that referral, 86% of patients prefer to receive mental health services from their facility team social worker. 17 Only 5% of patients refuse the SWI program at FMCNA and the quality of life benefits it can offer them. These types of onsite social work treatment programs can be quickly tailored to each patient’s unique set of barriers, and interventions can be provided during treatment at times when patients feel their best. Since these services can be delivered during treatment by providers normally on the treatment floor, patients are able to maintain a feeling of privacy when they receive needed counseling services.

In early screening, if no psychosocial risk barriers are identified the patient is moved onto a social work usual care pathway. This type of triage methodology helps the nephrology social worker continually focus more of their time on the patients most at risk of hospitalization and poor outcomes.  Social workers work quickly, utilizing tools that improve mood, adjustment and coping. They deploy demonstrated interventions that restore quality of life and reduce social and interpersonal distress 18,19 All interventions are tailored to address each patient’s specific risk area(s).

Symptom Targeted Intervention tools developed by Melissa McCool are also utilized in many cases to improve mood and overall psychosocial health. 20 Following an eight-week period of intensive social work intervention, these high risk patients are then moved to maintenance for close oversight and support. Social workers are provided with additional time to serve this program by reducing their scope of service. Tasks that do not require a master’s trained social worker (travel placement, data entry, admission paperwork, etc.) are moved to other team members as the social worker takes the lead in the more skilled behavioral health interventions.

Hospitalization: Reducing the risk

In the integrated care environment, patient risk of hospitalization is a constant area of focus. During the course of the SWI program, the social worker is just one member of an interdisciplinary team (IDT) that stays in very close communication about all risk areas. There are more frequent informal team “huddle meetings” on any patient considered to be at higher risk of hospitalization. More formal calls are held on a routine basis with the full IDT to review progress and reassess risk on all levels. The social worker’s role in all meetings is to keep the team fully informed of any psychosocial risk areas presenting. All team members learn from the social worker how to best provide “real-time” support to reduce the psychosocial risk of hospitalization. The constant assessment and sharing of interdisciplinary perspectives on these calls, reaching out to pull in experts and team consultants as needed, and operating in a real-time environment are examples of effective integration of care. The more frequent intervals of oversight on patients screened to be of higher risk of hospitalization is yet another example. The nephrology social worker is a key player in each of these processes.



Evaluating self-care

In addition to more attention on psychosocial risk, “usual care” models that serve the psychosocial needs of all patients (even those not considered at higher risk of hospitalization) are continuing to progress. Early assessment of patient self-care behaviors will allow the team to tailor interventions that advance patient engagement. These newer patient activation approaches, which have been shown to reduce cost of care in chronic illnesses such as diabetes, are likely to play key roles in working with incident patients who drive up considerable cost in the first 120 days of their admission to an outpatient dialysis center. 21-23 Working with the new patient, a nephrology social worker can ladder patients into feelings of confidence and mastery over their self-care while stabilizing their quality of life. The interrelationship of these forces (confidence, mastery and health related quality of life) is powerful in creating positive outcomes and there is, perhaps, no team member more skilled than the systems-trained social worker to mobilize those forces. Trained to help others maximize their life functioning, adapt to challenges and solve problems, the nephrology social worker is well positioned to steady the course for a patient, their family system, and the social systems around them. All patients benefit from this inoculation of life skills during their first 120 days of treatment and refresher support throughout the trajectory of their life with ESRD.

Accountable care in social work

The integration of care has also driven the field of nephrology social work into more accountability. Social workers are relying more than ever on the use of metrics, ensuring that psychosocial health is restoring at all times in those at risk and having a positive impact on treatment adherence and hospitalizations. In addition to tracking actual risks identified (such as depressive symptoms, sleep quality, HRQOL), they will be monitoring the efficiency of the interventions they are using, and improving intervention processes using that data. They will be tracking referral processes and case management activities to continually improve their care navigation activities. With access to resource data, social workers can also improve their advocacy efforts where community resource gaps exist.

In the integrated care environment, social workers will constantly identify population issues and address them with pathways that serve those population needs. Social work pathways focus on periods of the care continuum where psychosocial stressors are often magnified and might present more risk of hospitalization. Table 1 demonstrates some of the high-risk periods of hospitalization for all ESRD patients throughout their continuum of care. Social work pathways will focus and guide the patient more intensively during these periods to bridge additional support to the patient. Treatment planning is more intensive and outcomes are monitored heavily during these high-risk periods. Notice the interplay of bio-psychosocial forces in the risk periods displayed in Table 1 and the role of the MSW to help navigate those forces to maximize patient and family functioning and reduce risk of hospitalization.


Integrated care has brought changes to the field of nephrology social work. In turn, nephrology social work has brought innovative contributions to the field of integrated care. The new social work service delivery systems described in this article are sure to help the industry reach its goals to keep care patient-centered while maintaining quality and reducing the costs of treating end stage renal disease. Social workers are called to serve the needs of the client, the family, the community and the society at large. Nephrology social workers are right where they belong in the ESRD integrated care environment. They feel right at home.


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2.     Nissenson AR, Maddux FW, Velez RL et al. Accountable Care Organizations and ESRD: The time has come. Am J Kidney Dis. 2012; 59 (5): 724-733.

3.     Centers for Medicare and Medicaid Services Comprehensive ESRD Care Model Fact Sheet.Released:Tuesday, April 15, 2014. http://www.cms.gov/Newsroom/Newsroom-Center.html

4.     Spirit of Excellence Award for team. Breaking the cycle: Holistic approach boosts dialysis compliance. Modern Healthcare, Dec 17, 2012

5.     Oral presentation:  Johnstone S, Li NC, Maddux FW, et al. A social worker-initiated program to reduce fluid overload in hemodialysis patients. American Society of Nephrology, 2014. Philadelphia, Pa.

6.     Oral presentation: Johnstone S, Dombro L, Garza G. et al. Declines in hemodialysis patient physical and mental component scores before death. American Society of Nephrology, 2014. Philadelphia, Pa.

7.     Poster: Johnstone S, Li NC, Maddux FW, et al. Reducing hemodialysis therapy non-adherence: A social-worker initiated program. American Society of Nephrology Meeting, November 2014, Philadelphia Pa.

8.     Lopes AA, Bragg J, Young EW, et al. Depression as a predictor of hospitalization among hemodialysis patients in the United States and Europe. Kidney International 62: 199-207, 2002.

9.     Lacson E, Bruce L, Li NC et al. Depressive affect and hospitalization risk in incident hemodialysis patients. CJASN 9 (10) 1713-1719, October 2014

10.  Lacson E, Li NC, Guerra-Dean S, et al. Depressive symptoms associate with high mortality risk and dialysis withdrawal in incident hemodialysis patients. Dial Transplant (2012) 0: 1-8.

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14.  Boulware LE, Liu Y, Fink NE, et al. Temporal relation among depression symptoms, cardiovascular disease events, and mortality in end-stage renal disease: contribution of reverse causality. Clin J Am Soc Nephrol 2006; 1:496-504.

15.  Fan L, Sarnak MJ, Tighiouart H,et al. Depression and all-cause mortality in hemodialysis patients. Am J Nephrol 2014;40:12-18

16.  Johnstone S.  Depression management for hemodialysis patients: Using DOPPS data to further guide nephrology social work intervention. Journal of Nephrology Social Work, 26 (5), 18-31, 2007.

17.  Roberts J and Johnstone S. Screening and treating depression: Patient preferences and implications for social workers. Nephrology News and Issues, 20 (13): 43, 47-49, 2006.

18.  Johnstone S. Helping patients manage treatment recommendations: Start with quality of life!  Renal Business Today 8 (7): 16, 18.

19.  Johnstone S, Li NC, and Demaline J. The expansion of a social work behavioral health program: Helping dialysis patients manage fluid craving. Neph News Issues, 29:1, pgs. 30-35, 2015

20.  McCool M, Johnstone S, Sledge R, et al. The promise of symptom-targeted intervention to manage depression in dialysis patients. Neph News and Issues 25 (6): 32-37

21.  ParchmanML, Zeber JE, PalmerRF. Participatory decision making, patient activation, medication adherence, and intermediate clinical outcomes in Type 2 diabetes: A STARNet Study. Ann Fam Med. Sep 2010; 8(5): 410–417.

22.  Remmers C, et al. Is patient activation associated with future health outcomes and healthcare utilization among patients with diabetes? Jrnl of Ambul Care Manag 2009; 32:320-7

23.  United States Renal Data System Annual Data Report 2012. ESRD Chapter 1: Incidence Prevalence, Patient Characteristics and Mortality. http://www.usrds.org/2012/view/v2_01.aspx.