Disclosures: Witten and Browne report no relevant financial disclosures.
September 16, 2021
3 min read

High caseloads in dialysis impact social determinants of health

Disclosures: Witten and Browne report no relevant financial disclosures.
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Growing literature on social determinants of health suggests the critical importance of these social and psychological barriers to outcomes for people with kidney failure.

With COVID-19 impacting vulnerable populations, it is time to address potential mismatches between patient and staff needs and clinic resources.

The problem

The COVID-19 pandemic increased the risk of depression,1 anxiety2 and financial hardship3 for patients on dialysis. A study published in 20204 assessed the effect of the pandemic on in-center hemodialysis patients’ psychosocial health and found the following:

Beth Witten
  • almost 80% reported moderate to extreme worry about the effects of the pandemic on their mental/emotional health and interpersonal relationships;
  • more than 85% worried about getting dialysis due to risk from close contact in the clinic or during transportation;
  • 27% had clinical levels of depressive symptoms;
  • 33% reported poor sleep quality;
  • perceived stress was high in about 30%, with 85% feeling overwhelmed by the pandemic;
  • 90% were concerned about housing insecurity; and
  • 30% reported food insecurity.

A survey completed in 2020 by the American Nephrology Nurses Association 5 of nurses’ reactions to the pandemic found the following:

  • 67% frequently had trouble relaxing;
  • 47% had difficulty controlling worrying or fear; and
  • 62% felt burned out.

In the survey, 47% of nurses said work was “hardening their emotions,” which is a sign of compassion fatigue.

Opportunities for change

The ESRD Treatment Choices model, which launched in January, offers new opportunities for clinics to increase the rates of home dialysis and transplant. It is important to address critical psychosocial barriers to home dialysis and transplant. A payoff for patients choosing the best option is improved treatment “fit” and better health-related quality of life.

Vocational rehabilitation has always been a goal of the End-Stage Renal Disease program. According to the 2020 U.S. Renal Data System Annual Data Report, 23% of patients 18 to 54 years old were working full- or part-time from 2016 to 2018.6

Teri Browne

Helping patients who are willing and able to work to keep their jobs or find new ones has a big payoff: Patients experience reduced stress and greater financial stability, and clinics benefit from getting higher reimbursement from employee group health plans vs. Medicare payment.

A 2005 study found high caseloads at dialysis clinics in Connecticut limited social workers’ ability to provide clinical interventions to their patients.7 A national survey between 2014 and 2017 found social work caseloads increased for part-time and full-time social workers to an average of about 130 for a social worker working 40 hours per week, with part-time social workers having even higher relative caseloads.

With higher caseloads in 2017, “68% of social workers did not have enough time to do casework or counseling, 62% did not have enough time to do patient education, and 36% said that they spent excessive time doing clerical, insurance and billing tasks,” according to the survey results.8

We know depression and poor physical and mental function predict increased risk of missed treatments, hospitalization and death. Likewise, better staffing might reduce patient complaints and improve patient satisfaction scores – a win-win for patients, staff and clinics.