Nephrology Social Work: An Emerging Clinical Social Work Specialization Podcast

Editor's note: This text-based course is a transcript of the Nephrology Social Work: An Emerging Clinical Social Work Specialization Podcast, presented by Tiffany N. Brown, MSW, LMSW, and Benjamin T. Bencomo, DSW LISW, LCSW.

Learning Outcomes 

• After this course, participants will be able to:
  • Define nephrology social work.
  • Describe the patient population served by nephrology social workers and identify the needs associated with this population and the barriers to working with this population.
  • Identify basic nephrology social work assessment tools and interventions.

Podcast Discussion

Ben: Hello and welcome to this Social Work Podcast. I am Dr. Ben Bencomo, and I am very excited to welcome our guest today, Tiffany Brown. Tiffany Brown will be speaking to us today about nephrology social work. I am very excited to learn more about this area of practice. If I am being completely honest, until I connected with Tiffany, I had never heard of nephrology social work. There are many specialization areas of social work, and most are well-known. Nephrology social work is a super specialization within the medical category. I am very excited to learn more.

Tiffany Nicole Brown is a licensed master-level social worker who found her calling in the nephrology specialty in 2013. Originally from San Francisco, California, Tiffany found her new home and place of social work practice in Texas. She has worked for a dialysis company for nine years, where she has advanced into leadership positions, leading a team of social workers spread throughout the Dallas Motorplex, training other social workers and coworkers, and working in advocacy for the social work profession. She has served in leadership roles within the North Texas Nephrology Social Work Council of Dallas, Texas, as well as planning committees for patient advocacy events with the National Kidney Foundation. She is a Texas College and Howard University alum and is currently pursuing her clinical license in social work. She plans to provide additional adjustment therapies for dialysis patients through professional, private practice in the future. Tiffany, thank you so much for joining us today.

Tiffany: Thank you for having me. It is an honor to speak with you and the Continued family about nephrology social work. I have been waiting all week to tell you all about it. I told many colleagues about the experience that we are doing right now on this platform. This area of social work is my passion and niche. 

Ben: I have been excited about it as well. I am always interested to learn about people's path to social work and how social work found you. Can you share your path to social work, your educational background, and a few of your professional practice experiences?

Tiffany: Social work started for me as a young church and community girl. My parents were always giving back to the community through the church. I remember collecting shoes for kids who were in need at my church. "Social work" was instilled in me from a young age, thus, pursuing a degree in this field came naturally.

As you expressed, I went to Texas college and had a mentor, Rosalind Russell. She saw that I was a natural at helping people at school and in the community. I received my bachelor of science degree in social work at Texas College in Tyler, Texas. Rosalind and other mentors encouraged me to go further with my educational pursuits. As social work has grown, so have the requirements of working on a certain level. I chose to go directly into master-level study at Howard University, but I was not clear about where the direction I wanted to go. At the time, there was a big press for mental health. Although I received training in this area, as do all master's level candidates, I saw myself working in a healthcare setting. Something kept drawing me back to the hospital. My big goal was to get to the VA Hospital.

I took different opportunities that were connected to healthcare. My first job out of graduate school was in mental health at a community behavioral health agency. I was there for five years doing intense crisis services, which led me to my current path of crisis intervention in nephrology care. That was the foundation. I also worked in women's health in Fort Worth, working alongside the police department and connecting women to resources. Many of these women suffered from substance abuse, homelessness, prostitution, and things of that nature. I was out in the trenches, speaking to these women one-on-one, which is true direct service practice.

From there, I got into substance abuse prevention education with students in middle and high school. It was fun providing that education to them.

A year later, an opportunity opened up at a dialysis facility. I knew nothing about dialysis. I knew nothing about dialysis but thought it was another step toward my medical goals and the VA. I learned much about the fascinating treatment modality, dialysis, and how it keeps people alive. This unique population is trying to live despite all the barriers they experience, and it fascinated me. I found that nephrology social work was my niche that provided great learning opportunities. I have now been at this facility for almost ten years in September.

Ben: That is fantastic. It is always interesting how different social workers find their way into the profession and their niches. I am happy that you could follow your passion. Can you define nephrology social work?

Tiffany: Nephrology social work is a service that maximizes psychosocial functioning and adjustment to chronic kidney disease in patients and their families. Throughout our conversation, when I am speaking about chronic kidney disease patients, I am talking about patients who have end-stage renal disease and are on dialysis. There are different types of renal social work, including transplants, but my specialty is the direct service practice in the outpatient unit of a dialysis center.

The Council of Nephrology Social Work is under the National Kidney Foundation and has a standard of practice for nephrology social workers. They define the role of the nephrology social worker as a professional licensed in their applicable state and holds a master's degree in social work with a specialization in clinical practice. 

Ben: That answers some of my next question, which is the basic education and licensure level requirements of a social worker in this area. If someone is interested in the specialized area of nephrology social work, they need a master's degree in social work and a license within the state where they are practicing. This would be an LMSW or an LCSW.

Tiffany: Correct. To give a little more detail, you have to have at least two years of social work practice and one year specifically in a dialysis unit or transplant program. This requirement came about before September 1st, 1976, for the federal guidelines of ESRD social work professionals. Social workers must be in the dialysis unit per the Center for Medicare and Medicaid Services, and these requirements are standard for all dialysis units in the country.

Ben: I did not know that. How has nephrology social work evolved over the years?

Tiffany: When I started in nephrology social work, there was no considerable focus on the mental health aspect or barriers the patients experience. It was more about case management, referrals, and psychosocial assessments. It was about referring to the state, local, and federal agencies to help break the physical and psychiatric barriers of dialysis. There was also assessment, treatment plans, and meetings to determine the need for transportation or food stamps. We also looked to see if there were problems with access to care and connected them to medical homes if no one was coming into the unit.

Social workers are now the behavioral health professionals in the units, and we are respected as such. Before, our focus was on case management and putting out fires. We were not using our master's level behavioral training and diving into the root cause of the patient's experiences, such as poor patient outcomes, mistreatments, or lack of motivation/adherence to treatment regimens. As social workers, we deal with the whole person and have the opportunity to be behavioral health professionals.

Ben: Yes. As social workers, we have a holistic approach where we look at a person's biological, psychosocial, and spiritual aspects and how we can support them. Nephrology social work has enabled you to see more holistic support for people.

Tiffany: Oh, yes. We have come a long way. Social workers know this was coming through our training, especially with the National Kidney Foundation. We knew that we would be held accountable for that piece. We are looking into why they are at this stage and not adhering to the doctor's prescribed treatment regimen. The cognitive theory says that our thoughts control our feelings, which influence our behavior. We utilized this theory heavily in the dialysis unit and are being charged to use our clinical skills. I am excited about the change. We are not just professionals who collect and file applications. Instead, we are clinicians. 

Ben: How do you see that continuing to evolve based on the needs of today's patients and our expertise?

Tiffany: One piece of it requires the clinicians to be present in practice and in licensure. For example, some states now require that nephrology social workers have an LCSW instead of coming in with the LMSW. Florida requires social workers to come in with that LCSW to prove they are ready to go as we continue to walk in that walk of the behavioral health professionals in the unit. I also think we will see changes in outpatient dialysis units as more people do home dialysis and receive transplants but still need support. We will most likely be transitioning our services to outpatient and home care.

Ben: Do you feel that, in some ways, the COVID pandemic helped to accelerate not only outpatient dialysis but in-home dialysis as well?

Tiffany: Oh yes. That was a key conversation with many patients who were in the center at that time. It overwhelmed many people, and we saw an increase in anxiety. During the pandemic, social workers were first responders. We had to ensure the patients could get behavioral health and regular standard psychosocial services. COVID-19 significantly impacted how dialysis was being provided and the increase of home dialysis as well.

Ben: Could you walk us through a day in the life of a nephrology social worker? 

Tiffany: The dialysis unit is a large room with many recliner chairs, each next to a dialysis machine. Each patient has a time slot for when they come into the unit to receive their treatments, which can be up to four hours. Imagine sitting in a chair for four hours and keeping still while blood is transported through these lines, into a machine, and back into the body. One role of the social worker in this environment is a patient educator. We educate patients about their treatment options, facility rules, and conduct and responsibilities. We are the professionals who also check into health literacy with our patients. Do they understand what is going on with their diagnosis? Do they know why they are there? Do they understand the importance of adhering to their treatment regimens?

Social workers are also advocates. Patients have rights that need to be respected and upheld in the unit. Dialysis is a very vulnerable, trusting process. A person is allowing something to happen to them so that they can survive. It can also be anxiety-filled, especially when it comes to change. And there are always changes going on in the unit. We are there to advocate for that patient to make their voice heard.

We are also there to provide cognitive and behavioral interventions to increase the quality of life for patients in that unit. We want them to perceive and feel confident that they are getting quality care when they come into the unit. How do we do that? We are coaches and educate the team on how to have positive interactions with our patients. They all come from different cultures, backgrounds, and levels of understanding. We are there to encourage them to promote a calm environment. A dialysis unit is a place of healing, and we want it to reflect that.

We need to assess our patient's ongoing needs because we know that this lifestyle is new to them. It requires an adjustment process. We constantly evaluate new patients at certain intervals, like 30 days, 90 days, and annually through our plans of care and measure-based assessment tools.

We see each patient at least once a week and assess their barriers. We also build rapport with our new patients to help them adjust. As social workers, our relationship is crucial to maximizing the therapeutic process. We collaborate with the interdisciplinary team, including the nephrologist, registered dietician, and nurses. We also collaborate with other care partners in the community, like those from the American Kidney Fund, caregivers, and clinical providers outside the unit.

Ben: You have talked about ways social workers help increase positive patient outcomes. How do you interface with support systems that your patient might have, whether formal or informal support?

Tiffany: I like to tell my team to use those old genograms with the circles of support around the patients. We look at the patient's family, social contacts, and community resources. We also should add the cultural context as well. Most dialysis patients are people of color so being culturally competent is very important as a nephrology social worker because we want to know what works best for a particular patient. One of the interventions that a social worker may use is leveraging family as a support.

In addition to our measured-based practices, such as screening for depression through the PHQ9 and using measure-based practice tools, we can use the Distress Thermometer (DT), which was famously used for cancer patients. It also works very well with dialysis patients. 

Per CMS requirements, our original tool was the KDQOL, the Kidney Disease Quality of Life Instrument, which assessed several different aspects of the patient's life, whether it was mobility, depression, feeling like a burden, and the symptoms and problems that go along with being in dialysis. Nausea, itchiness, and dry skin are some of these problems. They have other concerns like pushing a vacuum cleaner, traveling, and being intimate with a partner. We use some of these tools to identify concerns and ways to decrease these barriers.

Ben: It sounds like a lot.

Tiffany: It is a lot. I want to go back to our earlier discussion about clinical practice, as you can now see how this impacts a positive dialysis outcome. Social workers are there for our patients, as this is our number one responsibility. We also work for dialysis companies with policies and goals in mind when working with our patients. With that being said, we also want to be effective contributors to the positive, quality outcomes for our dialysis facilities and clients by gathering information.

Ben: What are the most common mental health barriers you see, and what interventions do you utilize to help decrease some of those barriers to achieve positive patient outcomes?

Tiffany: Undoubtedly, depression is one of the most common mental health barriers at the ESRD dialysis outpatient facility. Patients who are on dialysis also have anxiety. Many patients also have co-occurring diagnoses, like substance abuse, bipolar disorder, schizophrenia, and dementia. The social worker's role in a dialysis facility is to gain information and collect symptomatology via the PHQ9 and other measures. If the person scores over five on the PHQ9, we can refer that information to the nephrologist, psychiatrist or psychologist, and other team members. We can also connect with family members about how the patient behaves at home. This may lead to further interventions like counseling or medication.

Ben: Interesting. Over the last few decades, more and more social workers have transitioned into private practice, especially at the clinical licensure level. This appears to be slowing down a bit lately. Do you see social workers transitioning into private practice from nephrology social work?

Tiffany: I see both. Many social workers transition to private practice, but I see them utilizing their LCSWs in the unit to impact clients. I have seen social workers pass their test and say, "I am going to go onto private practice," and that is okay. I have also seen social workers go from nephrology social work to establishing their private practice and seeing dialysis patients. There is much work for clinical social work in a dialysis facility, which is rewarding.

Ben: A little bit earlier, you spoke about the need for advocacy for patient rights and advocacy for services that your clients need. Can you discuss some of the ethical dilemmas you have experienced in nephrology social work?

Tiffany: The Center of Medicare and Medicaid Services is promoting and encouraging dialysis facilities to transition our patients from in-center dialysis into home peritoneal dialysis, hemodialysis, or a kidney transplant. The ETC model leads this five-year initiative, an incentive value-based program that rewards dialysis facilities and providers to transition or educate patients over to a home modality. Our places of employment may see this as a great thing. While there are pros to home dialysis, the pricing choice is something that this social worker has to always keep in mind. We must give patients information so they can decide what they need for their quality of life instead of what someone else might think is best for them. We must ensure that we are advocating for what a patient would like, as opposed to what others would like to see, whether it is the nephrologist, facility, or family member. We want to respect the patient's decision.  

Ben: What does ETC mean?

Tiffany: ETC stands for end-stage renal disease treatment choice. 

Ben: Can you speak more about what ETC intends to do? 

Tiffany: ETC is a model intended to encourage greater use of home dialysis and kidney transplants for Medicare beneficiaries with ESRD. One of the goals is to utilize home modalities and transplants more than outpatient dialysis. The third goal is to reduce Medicare expenditures because we know that dialysis is a big chunk of the CMS budget. There are over 700,000 dialysis patients in the nation. In 2018, they paid about $30 billion in dialysis treatments. The government decided that something had to be done.

Another goal is to decrease the disparities in access to care for different treatments, as most clients are black and Hispanic. Patients need to be educated on the different types of dialysis and the types of modalities available.

According to the National Institution of Diabetes, Digestive, and Kidney Disease, nearly 786,000 people in the United States live with end-stage renal disease, with 71% of them on dialysis and 29% with kidney transplants. For every white person who develops end-stage renal disease, three black people develop end-stage renal disease. There are four Hispanic persons who develop end-stage renal disease for every three non-Hispanic persons who develop end-stage renal disease. As you can see, there are disparities among the races. Regarding home dialysis and transplants, cultural implications might serve as barriers for these minorities. There is also fear of the medical community and decreased access to care for these populations, especially those of decreased social and economic statuses. Now, we see that clinics are encouraging patients to be educated about what type of dialysis they receive.

Ben: In one of our other podcasts, I spoke with the guest about the social determinants of health. In your professional experience, how do you feel those social determinants of health impact some of the disparities you are seeing?

Tiffany: It significantly impacts care, the perception of access to care, and what good care looks like to our patients. When the patients come into our facility, they are usually sick and may not even have insurance or know how they will get to dialysis. Many clients are not educated or have good health literacy, so the social implications are hefty.

I also wanted to revisit transplants. Transplants are now considered the number one treatment for end-stage renal disease. We want patients to apply and get transplants, but I wanted to mention that there is a disparity in wait times. The median wait time for a black adult is about 59.9 months, while for a white patient, it is about 41 months and 55 months for a Hispanic client. A non-Hispanic patient's wait time is about 47.4 months. As you can see, their access is different for these two communities. 

Ben: Why do you think we are seeing those disparities that we are not seeing in other patients?

Tiffany: The perception of healthcare, in general, is to take care of yourself and ensure you are checking in and have appropriate access to care. However, I cannot only blame it on "access to care" because there are hospitals and health workers in most communities. There are many different variables, so it is difficult to isolate one cause. Social workers need to ramp up our advocacy and ask more questions. It deserves a conversation on several different platforms.

Ben: Absolutely. Regarding nephrology social work, what are your beliefs on how social workers will be utilized in this specialization area in the future? 

Tiffany: I joke with my patients about home dialysis and transplant and say, "I may not have a job in the future." As patients become more aware of their options, these conversations are happening not only at a facility level but also at a patient level, even with their first occurrence. When kidney disease is first diagnosed, and they are in the hospital, there are conversations about what dialysis modality would be more appropriate. As we start to have those conversations at the hospital level, we may see fewer patients coming to our unit over time. Social workers are going to have to learn how to pivot. We may even have to go back to home visits. They are even talking about robotic kidneys.

Ben: Interesting. We are responding to changes in that need, and there is a cyclical pattern that the social work profession follows. I know you are also engaged in a great deal of macro social work practice in this area, like leadership roles with the North Texas Nephrology Social Work Council. You have worked to help plan for patient advocacy events and have done a lot of work for the National Kidney Foundation. Can you tell our listeners more about some of those advocacy efforts?

Tiffany: Working with the National Kidney Foundation and engaging with the dialysis community has been a pleasure. It is fulfilling to recognize patients who have been successful in their treatment options, getting transplants, and organizing different workshops for patients and their caregivers to hear about the progression of dialysis.

We know now that care partners are essential, especially for our ever-growing population of home patients. Recognizing that piece, there need to be services for them as well. They need to have support groups and places of respite. They need to have services available to them to be effective caregivers. They often have anxiety and worry about what will happen to their loved ones, so organizing these workshops for caregivers is crucial.

In addition to the National Kidney Foundation, there is also the ESRD network in almost area of the nation. They are patients' advocates and liaisons between the state and federal government and the facilities that provide dialysis treatment. They also offer support to caregivers.

Ben: Absolutely. I cannot imagine how much that need continues to grow year after year. Are these networks a combination of different state and federal entities working to raise money to support patients and their families? Are there other agencies working toward research, like robotic kidneys?

Tiffany: I am constantly communicating with the ESRD Network, and they often provide research-based quality improvement initiatives. They always offer mandated, research-based programs, some of which may be patient advocacy, caregiver engagement, or transplant education. Some instructions may be how we deal with our patients when referring them to home dialysis.

They also monitor how we are doing in the facility regarding transplant goals and patient complaints. The ESRD Network and the National Kidney Foundation have a fundraiser to raise money for advanced treatments for ESRD. There is also the American Kidney Fund which has a part in the continuum of care and assists patients financially by paying for their insurance premiums and emergency grants to patients with financial trouble. These are a few examples, but the ESRD Network is a large piece of patient advocacy and ensures that the facilities respect CMS guidelines.

Ben: It sounds like there is an opportunity for people interested in nephrology social work to engage in many different micro, meso, and macro practice areas. Many of our listeners may be interested in learning more about this specialized practice. Where can they go to learn more about this?

Tiffany: I would say a great place to start is the National Kidney Foundation. There is a link for the Council of Nephrology Social Workers. The standard of practice for nephrology social work is listed there. It will give you a comprehensive education on what ESRD is, chronic kidney disease, nephrology social work, et cetera. The great thing about nephrology social work is job security because we are mandated by the Center of Medicare and Medicaid Services to be in that unit. You cannot have a dialysis unit without having a nephrology social worker if they are receiving funds from Medicare and Medicaid, which makes our job unique. It is a multifaceted specialty that I love.

Ben: Nephrology social work, as you have described it, seems like it could be taxing physically, mentally, and emotionally. What do you do for your self-care to help you continue to be healthy and effective in working and supporting people in this field?

Tiffany: Nephrology social work is a very flexible specialty as we can create our schedules around our patients, and the work-life balance is there. For self-care, I like hiking and spending time with my family. You need to know your boundaries. When you are home, you are home; when on the unit, you are on the unit. Nothing goes on in the unit that cannot be connected to social work, so that is why self-care is so important. Even if a machine breaks down, that still relates to the patient's rights. If someone sticks a patient wrong and the patient complains, we may need to get involved. You have to know how to go home and have that boundary. 

Ben: The work-life balance is vital.

Tiffany: Yes.

Ben: I want to thank you for sharing your expertise and some of your practice wisdom in this specialization area. I have learned much about nephrology social work, and I am sure our listeners also have. Thank you for the work you continue to do with patients and their families.

Tiffany: Thank you for having me. It was such an honor to talk about this topic.

Ben: Thank you again.

References

Available in the handout.