Begin with the end in mind: the value of outcome-driven nephrology social work

The last decade has brought multiple changes in the delivery of care to patients with chronic kidney disease (CKD), and the nephrology social worker, like other members of the dialysis care team, has changed in response to a new health care climate. This article reviews a disease course perspective of CKD and the outcome-driven nephrology social work model of practice. The outcome-driven model is strategic and works toward improving patient outcomes. In this model, the social worker identifies and isolates barriers to desired treatment outcomes such as survival, quality of life, and cost containment and develops focused psychosocial interventions to reduce barriers to positive treatment outcomes. Measurement is the key to refining interventions to meet patient and clinic needs. Once an intervention is fine tuned, it can become a standard intervention in a "tool kit" that can be used by the social worker on micro- and macrolevels. This model of nephrology social work practice can improve treatment outcomes in areas such as depression management, fluid management, care planning, missed treatments, rehabilitation, satisfaction with care, and reduced hospitalizations.