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NEPHROLOGY SOCIAL WORK
Chapter 18Handbook of Health Social Work, 2nd Edition
Created by Teri Browne
End-stage renal disease (ESRD)- chronic condition that results in kidney failure and necessitates renal replacement therapy via hemodialysis, peritoneal dialysis, or a kidney transplant (also known as “chronic kidney disease stage 5)
ESRD is an important practice focus for social work because it provides the only Mediare mandate for MSW service provision for a disease or treatment category
END STAGE RENAL DISEASE AS A PUBLIC HEALTH ISSUE
ESRD is cause primarily by diabetes and hypertension, but also by:LupusGoutChemotherapyCancerSubstance AbuseOther kidney diseases (glomerulonephritis, nephritis, and polycystic kidney disease)
THE CAUSES OF ESRD
The average 2010 Medicare cost per patient for hemodialysis was $77,506 per year
The cost for peritoneal dialysis was $57,639
The cost for kidney transplantation was about $116,100 for the year in which the transplant was received and $26,668 per year after the transplant
COSTS OF ESRD
Hemodialysis- a medical treatment in which a patient is connected to a dialysis machine via tubing joined to an external catheter in the patient’s chest or needles inserted into a permanent vascular access (also called fistulas, grafts) that is usually in the arm which is attached to tubing that leads to the machine.
The machine consists of tubing, solution, monitors, and a filtering device called a dialyzer that removes excess fluid from the patient and cleanses the blood prior to its return to the body through tubing connected to the catherter or access.
WHAT IS HEMODIALYSIS?
In-center Dialysis- usually performed three times a week for at least three hours per treatment Monitored by nurses and patient care technicians Hemodialysis patients see the health care team while
receiving treatments
WHAT IS HEMODIALYSIS?- CONTINUED
Home hemodialysis is a treatment option that allows patients to perform their own dialysis at home
Patients and social suport network members receive comprehensive training
Equipment and supplies are delivered and set up in the home
Home hemodialysis provides a more comfortable environment for the patient and eliminates travel
Patients see their dialysis teams when they return to the dialysis clinic for laboratory testing and follow-up visits
WHAT IS HOME HEMODIALYSIS?
Peritoneal dialysis is a renal replacement treatment modality that is conducted by patients themselves
A catheter is surgically implanted in patients that protrudes from the abdomen
This is dne daily, either several times throughout the day or overnight via a machine
Peritoneal dialysis patients see their healthcare team during monthly visits to the clinic
WHAT IS PERITONEAL DIALYSIS?
Kidney transplantation is a surgical procedure in which a donor kidney is placed in the ESRD patient’s body
The donor kidney can be deceased or a living donor
It involves extensive evaluation and testingIf a living donor cannot be located, the patient is
placed on a waiting list for a deceased donor kidney
WHAT IS KIDNEY TRANSPLANTATION?
An altruistic kidney donation is when a person gives their kidney to someone they do not know personally
A growing phenomenon in kidney transplantation is called “paired donors”
An example of paired donors can be found on page 470
WHAT ARE ALTRUISTIC KIDNEY DONATIONS?
Acute dialysis was first done in the 1940sThe first kidney transplant was performed in 1951Chronic outpatient dialysis was first available in the
early 1960sIn 1965, there were only 200 dialysis patients in
the worldBefore 1972, hemodialysis machines were scarce
and dialysis was largely paid for by patients or with donated fundsSelection committees chose individuals for dialysis based on their “social worth” Preference was given to breadwinners and community
leaders
A QUICK HISTORY OF DIALYSIS
On October 30, 1072- the national ESRD program, Public Law 92-601 was passed This law provides Medicare coverage of dialysis or kidney
transplantation for all ESRD patients regardless of age This coverage is unique, because ESRD is the only disease
category that guarantees Medicare eligibility
A QUICK HISTORY OF DIALYSIS- CONTINUED
Individuals 65 years and older are the fastest increasing population among ESRD patients today This group has more comorbidities, greater psychosocial
issues and needs, and more physical problems Certain groups in the United States are effected
disproportionately: African-Americans Hispanics American Indians Alaskan Natives
White American males are more likely to receive a kidney transplant than any other demographic group in the United States
DEMOGRAPHICS OF RENAL PATIENTS
Lack of preventative carePatient preferenceSocioeceonomic disadvantageDistrust of the medical communityLack of knowledge about kidney transplantationMedical reasons
REASONS FOR DISPARITIES
89% of ESRD patients report experiencing significant lifestyle changes from the disease
Psychosocial barriers to ESRD care: Adjustment and coping to the illness and treatment regime(s) Medical complications and problems Issues related to pain, palliative care, and end-of-life care Social role adjustment: familial, social, and vocational Concrete needs: financial loss, insurance problems, prescription
coverage Diminished quality of life Body image issues Numerous losses; financial security, health, libido, strength,
independence, mobility, schedule flexibility, sleep, appetite, freedom with diet and fluid
PSYCHOSOCIAL ASPECTS
ESRD may impair sense of taste, diminish appetite and cause bone disease that can require surgery and impair a person’s ability to walk
ESRD patients may have anemia and uremia, which lead to confusion, lethargy, and sleep problems
Dialysis patients often must take several phosphorous-binding tablets with every meal as well as numerous other medications (some take up to 25 pills a day) Self-management of oral medications is a significant problem
Researchers have found ESRD patients to be significantly more likely than others to commit suicide
DISEASE- RELATED PSYCHOSOCIAL ASPECTS
Researchers have noted that ESRD results in anxiety and depression More likely to have poor nutritional outcomes Higher mortality rate Malnutrition Less likely to adhere to their recommended treatment
regimes Depression can lead to hospitalization
ANXIETY AND DEPRESSION AMONG
ESRD PATIENTS
Insomnia and sleeping problemsBody image issues
Vascular accesses for hemodialysis can become quite large and visible on patients arms
Peritoneal accesses and catheters are surgically implanted and protrude from the body
Immunosupporessant drugs and other medications can cause weight gain and other physical changes
Decreased rate of fertility among female ESRD patients
Acute and chronic pain from surgeries, cramping, needlesticks, neuropathy, and bone disease
OTHER DISEASE-RELATED PSYCHOSOCIAL ASPECTS
Difficulty coping with the illness and treatment regimes
Financial burden/loss of incomeExtra time needed to care for patients and
transport them to treatmentsLimits work hours
IMPACT ON FAMILIES
ESRD patients are required to assume strict diets
Extreme weight gain between dialysis treatments can lead to discomfort during hemodialysis and removal of excessive fluid results in severe cramping and low blood pressure
Peritoneal dialysis patients have much less restrictive dietary and fluid intake restrictions
Transplant patients normally are not required to follow renal diets or limit their fluids
TREATMENT-RELATED PSYCHOSOCIAL ASPECTS
Barriers to quality diet may include patients’ education and literacy level
Insurance may not allow patients to obtain recommended nutritional supplements
Social support availability is also related to poor diet because ESRD patients may need assistance to purchase groceries and prepare meals
RAMIFICATIONS OF PSYCHOSOCIAL ISSUES
The significant psychosocial issues faced by ESRD and their families requires social work intervention This practice is known as nephrology social work, or renal
social work
Medicare mandates that a master’s level social worker be on staff in every dialysis center and kidney transplant program
The focus of these social worker’s is to imporove the patients ability to adjust and cope with chronic illness and the healthcare system’s ability to meet the needs of the patient
SOCIAL WORK INTERVENTION
Social workers are included on renal medical teams (which also include the patient, their family members, the nephrologist, the nurses, dieticians, patient-care technicians, surgeons, and pharmacists)
Sudies show that a team approach to patient education (which includes a social worker) is more successful than a single-disciplinary approach
A report on morbidity and mortality of dialysis by the National Institutes of Health claims that social and psychological welfare and the quality of life of the dialysis patient are favorably influenced by the involvement of a multidisciplinary team
SOCIAL WORK INTERVENTION- CONTINUED
Nephrology social work interventions tend to be valued by patients 1994 survey found that 90% of ESRD patients believed the
“access to a nephrology social worker was important”Patients relied on nephrology social workers to
assist them in coping, adjustment, and rehabilitation
Dialysis patients have ranked a “helpful social worker” as being more important to them than nephrologists or nurses
Dialysis patients also found that social workers were twice as helpful as nephrologists in aiding the patient in deciding between hemodialysis and peritoneal dialysis for treatment.
SOCIAL WORK INTERVENTIONS- CONTINUED
AssessmentCounselingEducationCrisis InterventionEnd-Of-Life CareCase ManagementRehabilitation
AssistancePatient Advocacy
NEPHROLOGY SOCIAL WORK TASKS
Nephrology social workers conduct an assessment of patients’ phsychoocial statust to identify their strengths, needs, and the areas for social work intervention
Assessments are completed for every dialysis and transplant patient and take into account each patient’s social, psychological, financial, cultural, and environmental needs
Social workers also assess transplant donors
ASSESSMENT
Nephrology social workers provide emotional support, encouragement, and counseling to patients and members of their support networks
ESRD patients may have difficulty adjusting to the illness and treatment regimes, social workers help them cope by providing education and counseling to decrease depression
One study found that 76% of depressed dialysis patients indicate that they prefer to seek counseling from the nephrology social worker rather than pursue care from an outside mental health practitioner
COUNSELING AND EDUCATION
Nephrology social workers provide crisis interventions in dialysis and transplant units to patients who may act inappropriately during hemodialysis, (i.e yelling at staff or other patients, threatening violence)
Social workers often effectively mediate conflicts in dialysis settings
CRISIS INTERVENTION
Social workers provide end-of-life care and information to ESRD patients and their families.
Terminally ill ESRD patients and their families welcomed more emotional support and other interventions from social workers.
ESRD workgroup for nephrology social workers entitled “Promoting Excellence in End-Of-Life Care”
END-OF-LIFE CARE
Social workers provide information to patients and their families about resources and information that are unknown to the family
Renal Social workers routinely provide case management services, including information, referrals, and linkages to local, state, and federal agencies and programs
CASE MANAGEMENT
Social workers help patients maximize their rehabilitation status by assessing barriers to patient goals of rehabilitation, providing patients with education and encouragement, and providing case management with local or state vocational rehabilitation agencies
Different roles for social workers related to rehabilitation are: Enabler/facilitator; Educator/advocate; and Administrator
REHABILITATION ASSISTANCE
Nephrology social workers collaborate with the renal team in providing patient care by participating in quality assurance programs, team care planning, and training of other health-care professionals on the topic of psychosocial issues
The 2008 Medicare Conditions for Coverage for dialysis units mandate that every unit implement a Quality Assessment and Performance Improvement (QAPI) program to assess patient and clinical outcomes
TEAM COLLABORATION
Social workers advocate for their patients within their clinics as well as with community agencies (see box 18.4 text)
Social workers also advocate for patients on a systems level with various organizations and governmental agencies
Renal Social Workers can help patients navigate complex systems of service provision, and advocate for patients with community providers that are not familiar with their special needs
ADVOCACY
Nephrology social workers are committed to social reform and influencing policy and programs affecting renal patients
Social workers also are employed in macrolevel services to the ESRD community: i.e clinical managers, social work directors, social work coordinators, researchers, and board members of agencies
COMMUNITY-LEVEL SOCIAL WORK
Social workers must often assume responsibility of clerical tasks (transportation arrangements, information on medicare/medicaid, etc.) although these tasks hinder social workers ability to provide clinical services to patients and their families
Surveyed social workers spent 38% of their time on insurance, billing, and clerical tasks versus 25% on counseling and assessing patients
PROFESSIONALIZATION OF NEPHROLOGY SOCIAL WORKERS
Positive correlation between job satisfaction and the amount of time spent in counseling, educating patients
Negative correlation between job satisfaction and time spent with insurance and clerical tasks
Large caseloads linked to decreased patient satisfaction & less successful patient rehabilitation outcomes
PROFESSIONALIZATION OF NEPHROLOGY SOCIAL WORKERS
(CONTINUED)
Affiliated with NKFGoals
promote patient, public, professional education ensure qualified social workers are in ESRD settings
Lobbied for inclusion of master’s-level social workers on renal teams
Annual training program, publications, newsletter, set policies and practice
COUNCIL OF NEPHROLOGY SOCIAL WORKERS
ESRD significant public health concernNephrology social workers proved effectiveSocial workers have various practice settings and
work with a variety of clients
CONCLUSION