Abstract: TH-PO0991
Preliminary Findings of a Pilot Community Health Worker Intervention for Patients on Hemodialysis Experiencing Health-Related Social Needs
Session Information
- Diversity and Equity in Kidney Health
November 06, 2025 | Location: Exhibit Hall, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Diversity and Equity in Kidney Health
- 900 Diversity and Equity in Kidney Health
Authors
- Novick, Tessa Kimberly, The University of Texas at Austin, Austin, Texas, United States
- Osuna-Diaz, Michelle Marie, The University of Texas at Austin, Austin, Texas, United States
- Jacobs, Elizabeth A., University of California Riverside, Riverside, California, United States
- Crews, Deidra C., Johns Hopkins Medicine, Baltimore, Maryland, United States
Background
Health-related social needs, such as housing and food insecurity, are common among hemodialysis patients. Patients report that social needs cause emotional distress and often lead to missed treatments and hospitalizations. Community-health worker (CHW) assisted patient navigation interventions have been successful at addressing social needs in other populations.
Methods
We piloted a two-month CHW intervention for in-center hemodialysis patients with low socioeconomic status at four facilities in Austin, Texas and measured treatment attendance, hospitalizations, perceived stress, anxiety, post-traumatic stress, and depression at baseline and 6 months.
Results
Among 21 participants, mean (SD) age was 58 (9) years, 67% were male, 43% identified as Black, 52% as Hispanic, and social needs were common (70%, 65%, 47%, and 24% reported housing, food, transportation and utility needs, respectively). During the month prior to enrollment, missed treatments and hospitalizations were common (Table). Baseline perceived stress was elevated (81% reported moderate or high stress), and most participants screened positive for probable generalized anxiety disorder (62%), major depressive disorder (57%), or post-traumatic stress disorder (57%). There were 5 deaths (24%). At 6 months there was a trend towards improvements in hospitalizations and symptoms of anxiety and depression.
Conclusion
Interventions that address health-related social needs may secondarily improve mental health and clinical outcomes.
Hospitalizations, Missed Treatments and Mental Health Parameters at Baseline and 6-Months
| Characteristic, mean (SD) range | Baseline (N = 21) | 6-Months (N = 16) | P-value |
| Hospitalizations in the past 30-days | 0.4 (0.5), 0-4 | 0.3 (0.5), 0-1 | 0.7 |
| Missed sessions in the 30-days | 0.9 (1.2), 0-4 | 0.9 (1.5), 0-5 | 0.8 |
| Generalized Anxiety Disorder 7-item | 11.9 (6.2) | 8.3 (5.4) | 0.3 |
| Primary Care Post Traumatic Stress Disorder Screen | 3.2 (2.1) | 3.3 (1.5) | 0.4 |
| Patient Health Questionnaire-2 | 3.5 (2.3) | 2.5 (2.3) | 0.7 |
| Perceived Stress Scale | 21.3 (6.6) | 21.8 (6.5) | 0.6 |
Note: Follow-up measures were available for 16 participants due to deaths.
Funding
- NIDDK Support