Throughout the Campaign, the PEAK Learning Center will feature approaches that providers, health care professionals, and patients can focus on to improve survival in their first year of dialysis.

This month the Campaign spotlights three Best Practices—one family engagement practice and one technical/clinical practice on depression screening and management, including tools and resources to implement them, are available through links to the right.

The best practices have been recommended by the Patient/Family Engagement Expert Panel and the Technical/Curriculum Expert Panel. Each practice presents the interventions to achieve the practice, along with tools and resources for patients, healthcare professionals, and providers.



Depression adversely affects quality of life and is associated with greater morbidity, mortality and poorer adherence to prescribed care, and therefore requires attentiveness to screening and management.


  1. Screen and detect all ESRD patients for depression, using acceptable tools, at treatment initiation
    and yearly thereafter, or as depression is suspected.
    1. Establish a policy and implementation procedures to ensure depression is detected and
    2. Establish procedures for operationalizing the above policy.
      1. Write procedures that explicitly name who will be responsible for depression screening (e.g., MSW), and who refers depressed patients for treatment and follows and monitors those patients.
      2. KDQOL‐36 should be administered in the first four months and at least annually thereafter, or according to current regulations and guidelines
    3. Select a tool or tools for depression screening. Include a checklist to assure differential
      diagnosis is considered and adequately evaluated. Agree on a cut‐off score that triggers
      intervention and follow‐up interval. Anyone who screens positive should have their diagnosis confirmed with a diagnostic interview.
    4. Educate all members of the Interdisciplinary Team to recognize common signs and symptoms of depression, depressed mood, and modifiable factors (loss of appetite, under nutrition; sleep disorders; diminished pleasure in ADLs; poor adherence to dialysis, diet or medication regimen; social withdrawal; changing complaints including pain; psychosis; increased irritability, hopelessness, helplessness; trend for change in weight). Identify routine screening questions for staff during dialysis sessions (e.g., "down in the dumps;" "downhearted and blue". (Note: Patients can mask symptoms of depression: they may not be apparent.)
    5. Record positive or negative findings in Patient Assessment and Plan of Care.
  2. Recognize that management of depression – especially major or incapacitating depression ‐ may
    require the time and expertise of mental health professionals. Not all dialysis center staff members
    will be equipped to diagnose and treat this condition. However, they ARE in a position to:
    1. Identify patients at risk for or with depression signs (see 1.d. above) and ensure these
      observations are documented
    2. Initiate appropriate referrals and liaise with other professionals who may become involved
    3. Take steps to inform patients about the prognosis of depression, treatment options and the
      risks benefits and burdens of the treatment options as listed below. Share decisions with the patient and discuss with the patient about one or more of the following as they may pertain to signs and symptoms, such as those in 1(d) above:
      1. Counseling for coping skills to overcome fear, anxiety, sadness, poor adjustment, burnout, etc.
      2. Patient to patient support and mentoring
      3. Medication options (noting appropriate dose and/or timing adjustments)
      4. Modifiable treatment‐related problems, including the discussion of alternative ESRD treatment modalities that may better fit patients' preferred lifestyles
      5. Strategies that mental health experts may be able to implement (e.g., cognitive‐behavioral therapy)
    4. Agree on a schedule for recurrent assessment for those where treatment is initiated or changed for depression to determine treatment response and need for regimen or dose change, consistent with current guidelines for any depressed patient.
    5. Record treatment or referral in Plan of Care.
    6. Control depression by medication adjustment or referral for continual follow up.
  3. Monitor depression symptoms over time.
    1. Record status of depression in Plan of Care over time.
    2. Monitor depression detection, treatment and control in the aggregate of ESRD patients in the facility's Quality Assessment and Performance Improvement Program.
    3. Identify and employ tracking tools to assure assessments are performed, reported and results generate a trackable action, consistent with the facility's QAPI program.
  4. The social worker will evaluate the psychosocial needs in the initial assessment (within first 30
    calendar days or first 13 dialysis treatments), and subsequently as required by The Conditions for
    Coverage. Establish a quality target for proportion of patients assessed on schedule; adjust goals as targets are reached.
  5. Assess and periodically reassess cognitive status to determine if improvement has occurred and
    after patient has clearly responded to depression intervention.
  6. Identify care partner stress/depression among home and in‐center dialysis families.
    1. Have counseling resources and support groups identified and readily available to refer to as

Family Engagement Tools and Resources


Coach families, friends, and caregivers in the principles, techniques, and value of partnering with the patient and his or her inter-disciplinary health care team.


  1. Teach families and caregivers about the defining attributes of partnerships, including:
    1. A genuine and trusting relationship
    2. Honest and open communication and listening
    3. Praise and encouragement
    4. Reciprocity
    5. Empathy
    6. Respect for each other's expertise
    7. Working together with negotiation of goals, plans and boundaries
    8. Participation and involvement
    9. Support and advocacy
    10. Willingness to share information
    11. Commitment to "enable choice and equity" (Bidmead & Crowley, p.206)
  2. Teach families and caregivers communication skills that allow them to effectively partner with the
    health care team and advocate for the patient. These skills include the ability to:
    1. Negotiate
    2. Share decisions
    3. Collectively solve problems
    4. Establish goals
    5. Take action
    6. Identify strengths and weaknesses
    7. Clarify roles and responsibilities
    8. Evaluate progress (refer to "New Health Partnerships" under Tools)
  3. Help caregivers focus on coping skills and resources, including:
    1. How to communicate with the patient
    2. Where to find support services
    3. How to be an advocate for the patient
    4. How to recognize caregiver stress
    5. The Importance of caring for self
    6. How to develop individualized strategies to reduce stress
  4. Teach families and caregivers how to optimize care‐giving when they can't be there, including how
    1. Assess the multi‐faceted needs of the patient, from health care to living assistance
    2. Develop a plan of care
    3. Provide on‐going support and education
    4. Communicate with the healthcare team
    5. Seek help from neighbors and friends
    6. Use community resources for care
    7. Seek out technologies that connect families to the patient and to health care providers (see
      Technologies under Tools)
    8. Organize transportation, meals, recreation, etc.
    9. Mobilize resources during an emergency
    10. Choose professionals that specialize in Geriatrics
    11. Manage documents, insurance, and legal matters
    12. Care for themselves
  5. Guide caregivers in partnering effectively with senior housing, home health care, assisted living, and nursing homes to ensure communication across all settings.


Campaign Learning Center Resources

Right Start Program

Renal Physicians Association

Patient Tools and Resources

Technical/Clinical Tools and Resources Family Engagement Tools and Resources

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