Missed Dialysis Treatments and Health-Related Social Needs

The clinical decision: what will make the next treatment possible?

Meet people where they are. A missed treatment is a reason to check safety, listen, and solve a problem together. It is not a sufficient explanation to write “noncompliant.” A person may understand that dialysis is necessary and still have no reliable ride, no childcare, an inflexible employer, or a treatment experience they dread. Patient interviews show that knowing the risks does not remove the barriers [6,9].

Health-related social needs are individual circumstances that interfere with health or care: food, housing, transportation, utilities, safety, and financial strain. They sit alongside clinical symptoms, treatment burden, communication needs, and personal goals [1]. The useful question is: “What got in the way, and what can we change before your next treatment?”

This page offers a practical team approach, informed by patient research and established screening resources. It is not a validated attendance intervention or a promise that a screening form will prevent missed treatments.

1. First check safety and arrange the treatment plan

After an unexpected absence, follow the unit's outreach pathway promptly. Confirm whether the person is hospitalized, receiving dialysis elsewhere, unable to travel, or choosing not to attend. Ask when they last completed dialysis and about current symptoms. A transport problem and an acute medical problem can coexist.

Severe breathlessness, chest pain, syncope, confusion, or concerning weakness/palpitations require urgent clinical assessment. Use the emergency pathway when indicated. Missed dialysis can allow fluid and potassium to accumulate; feeling well does not establish that it is safe to wait [10].

Notify the responsible clinician and coordinate the timing and setting of the next treatment. The clinician determines whether examination, laboratory testing, or emergency evaluation is needed. Do not automatically defer to the next routine slot, independently change the prescription, or try to recover missed time through aggressive ultrafiltration. Confirm both the treatment slot and a feasible way to get there and home.

An unanswered call does not explain the absence. Use the agreed safe contact method, document attempts, and escalate according to unit policy and clinical concern. Avoid leaving sensitive information in a message that others may see.

2. Start with understanding, not a lecture

Choose a private, unhurried moment when the person is able to talk. Ask permission, explain why the question matters, and use an interpreter or accessible communication support when needed [3,8].

Connect: “We missed you and wanted to make sure you were okay.”
Invite the story: “Can you walk me through what happened on treatment day?”
Acknowledge the difficulty: “That sounds exhausting. Thank you for telling me.”
Find the priority: “Which part is making it hardest to come or stay for the full treatment?”
Build the next step: “What would make the next visit workable? What could our team change?”
Confirm the plan: “So I know I explained it clearly, how will the plan work if the ride falls through?”

These are suggested conversation prompts, not quotations from a screening instrument. Listen before offering solutions. Explain medical risks plainly and without threats. Invite a support person only with the patient's agreement, and do not assume a family member is available, safe, or able to take on more work.

3. Understand the reason, then match the response

Use the person's account to guide the next question. Several barriers may be present at once; start with the one that threatens the next treatment. The table is a practical discussion guide, not a substitute for the unit's formal assessment [2,3,6,9].

What may be getting in the way	What to understand	A practical team response
Transportation	No-show ride, long wait after dialysis, inaccessible vehicle, stairs, cost, unsafe weather, or pickup before treatment is finished?	Coordinate with scheduling and social work; confirm pickup and return times, mobility assistance, and a backup contact. Check that the ride works for the full prescribed session.
Work, caregiving, or competing appointments	Lost wages, shift changes, childcare, dependent-adult care, or another essential appointment?	Explore available shift changes, appointment coordination, and support resources. Confirm what is feasible rather than promising an unavailable chair time.
Feeling worse during or after dialysis	Cramps, hypotension, nausea, access pain, needle fear, severe fatigue, or prolonged recovery?	Request nursing and clinician review of symptoms, access, treatment tolerance, and the prescription. Explain what will be addressed before the next visit.
Food, housing, or utilities	Enough food now? A place to sleep, store medicines, prepare meals, or keep a phone charged? Are utilities or home-dialysis conditions unsafe?	Involve social work and the renal dietitian. Build a food plan around what is accessible. Home-therapy teams assess supply, power, water, and contingency needs.
Medication or other costs	Is the difficulty the copay, insurance interruption, refill, pharmacy trip, or confusing directions?	Connect the patient with the pharmacist, prescriber, and financial counselor. Verify that the medicine was obtained; do not just issue another prescription.
Emotional distress, fear, or loss of trust	Depression, anxiety, trauma, conflict in the unit, isolation, or concern that treatment no longer fits their goals?	Offer a private discussion, behavioral-health or peer support where available, and clinician review. Ask what would help the patient feel heard and safe.
Communication, memory, mobility, or caregiver strain	Hearing, vision, language, literacy, telephone access, cognitive change, difficulty transferring, or an overwhelmed helper?	Use accessible instructions and teach-back, assess support needs, and agree on reminders and contact methods that the person can actually use.

A portal message cannot solve a disconnected phone. A diet handout cannot supply food. A standing ride order does not establish that the vehicle arrived. Match the intervention to the actual barrier and check that it worked.

4. Use the HRSN survey to understand the patient and re-engage them

What the survey asks—and what it does not tell us

The CMS Accountable Health Communities (AHC) HRSN screening tool uses 10 core questions across five domains: living situation, food, transportation, utilities, and interpersonal safety. Eight supplemental domains cover financial strain, employment, family/community support, education, physical activity, substance use, mental health, and disabilities [2]. Use the official tool and its domain-specific interpretation; there is no single overall “dialysis adherence score.” A positive response identifies a possible need to explore. It does not establish why a particular treatment was missed, a psychiatric diagnosis, or the patient's willingness to receive help.

Open the official CMS AHC HRSN survey · Read the CMS implementation guide

Why this matters in dialysis

Attendance and laboratory results show part of the story; the survey helps us ask about the life in which the treatment plan must work. Dialysis attendance research shows that patients may know the consequences of missing treatment while still facing transport difficulties, treatment burden, and limited support [6,9]. These findings explain why repeating the risks can miss the reason the patient is struggling. The HRSN survey provides a structured opening for that conversation; its use should lead to a more realistic plan.

Consider the following dialysis applications of the survey, rather than treating a positive response as a completed task:

A transport need: clarify whether the problem is booking, pickup reliability, wheelchair access, cost, or a return ride that arrives before dialysis ends. Each calls for a different response.
Food or housing insecurity: ask what food is actually available and whether there is a workable place to store medicines, prepare meals, and recover. Review the nutrition and medication plan in that context instead of assuming a handout can be followed.
Financial strain or limited support: explore the tradeoffs between treatment, paid work, dependents, medication costs, and the help available on treatment days. Ask what the patient is having to give up to attend.

These are clinical applications proposed here, not extra scored AHC questions. Understanding where a person really is includes their strengths, priorities, and preferences—not only their unmet needs. Ask what already works, who they trust, and what they most want to regain through treatment.

Make it safe and useful to answer

Offer screening consistently rather than selecting patients because they appear disadvantaged. Explain its purpose and the help the team can realistically offer. Provide privacy, language/accessibility support, and an appropriate time to respond; follow the CMS implementation guide and the unit's approved process [3]. A suggested introduction is: “We ask about everyday needs because they can make dialysis hard to manage. Would you be willing to talk about what is getting in the way and what help would matter to you?” This is original suggested language, not a screening-item quotation.

Offer assessment at entry to care and revisit it after missed or shortened treatments, hospitalization, loss of housing or employment, changes in support, or a change in function. This is a suggested workflow, not a universal mandated interval. A past negative screen does not exclude a new barrier. Ask sensitive safety questions privately, explain confidentiality limits, and use the local safeguarding pathway when needed [3]. Record a declined question as declined, not as “no need.”

Translate a result into a re-engagement plan

After reviewing the answers, ask the patient to correct the team's understanding: “Have we understood what is making treatment hard? Which of these would you like us to work on first?” A positive screen, a request for help, consent to a referral, connection to a service, and meaningful improvement are distinct steps.

For each priority, connect the survey response to the next treatment: what must change, what the patient wants the team to do, who accepts the task, and how the patient can reach that person. Include a backup if the first arrangement fails. Confirm a safe, feasible treatment plan with the responsible clinician; do not make assistance or return to care contingent on completing the survey or accepting a referral.

On return, welcome the patient and acknowledge the work it took to come. Ask whether the agreed help arrived and whether it made attendance easier. If it did not, revise the plan together. Re-engagement means restoring a workable connection to care and trust in the team; attendance is one outcome of that work. A referral list or a completed survey alone does not demonstrate that it happened.

A practical team review should distinguish “not yet reached,” “declined for now,” “waiting for a resource,” “service unavailable,” and “patient reports improvement.” The HRSN tool is not presented here as a dialysis-specific, validated predictor of missed treatments, and this proposed workflow is not a proven attendance intervention. Its value should be judged by the patient's experience, whether agreed assistance was delivered, and whether access to needed treatment improved.

5. Make one achievable plan and close the loop

Agree on one priority with the patient, then name the action, the person responsible, and when the team will check back. The nurse identifies immediate safety and treatment issues; social work can coordinate benefits and community resources; the dietitian, pharmacist, scheduler, clinician, and home-therapy team each address the part they can change. Confirm that the receiving person has accepted the handoff.

A useful sequence is: barrier identified → patient agrees to help → handoff accepted → service reached → patient confirms whether it helped. The final step matters. A list of telephone numbers or a referral order is not evidence that a need was met.

At the next contact, ask: “Did the plan work? What is still hard?” If a ride failed again or a service has a waiting list, revise the plan with the patient and document the gap. Do not make the patient repeatedly retell the same story to restart the process.

Illustrative example: A patient leaves early because the ride service arrives before dialysis ends. The team confirms the patient's account, coordinates a later pickup and backup contact, and checks after the next session that the full treatment and return ride were possible. Education about treatment time may still help, but the essential change is correcting the pickup arrangement.

6. Document the barrier and the response, not a character judgment

Record the missed or shortened session, the patient's stated reason, relevant symptoms, what the patient wants help with, and what the team did. Describe facts and uncertainty. For example: “Patient reports transport did not arrive; wants assistance arranging the next treatment,” rather than a global label about motivation.

A concise handoff can follow this structure:

Treatment and safety: last completed session, missed/shortened time, symptoms, clinician contacted, and the treatment plan.
Patient's account: barrier in their own words and the priority they identified.
Agreed action: who accepted the task, appointment/ride details when confirmed, and the backup plan.
Follow-up: safe contact method, date/owner, whether the service was reached, and whether the patient says the barrier improved.

Record only the sensitive detail needed for care, in the appropriate record. Distinguish declined assistance, inability to contact, referral pending, resource unavailable, and need resolved. None is interchangeable with a completed screening box.

7. When missed treatments recur, reconsider the plan

Recurrent absence may reveal an unresolved transport problem, depression, an intolerable treatment experience, inadequate support, or a mismatch between dialysis and the person's goals. Reassess instead of repeating the same instruction more firmly [6,9].

A statement such as “I cannot keep doing this” deserves an open conversation. Clarify whether the person means today's symptoms, the schedule, a practical barrier, emotional distress, or a wish to reconsider treatment. Assess immediate safety concerns and involve the responsible clinician. A decision about ongoing dialysis needs informed, supported discussion; neither a single missed visit nor frustration establishes that decision.

Modality, schedule, symptom treatment, and supportive kidney care can be discussed with the clinical team when relevant. Home dialysis should not be presented as an automatic solution to transportation or attendance problems: home conditions, support, preferences, and treatment demands still matter [6].

8. What the evidence supports—and what it does not

Evidence	What it contributes	Limit to the conclusion
Chan et al., 2014: observational analysis of 44 million treatments in 182,536 patients [4]	Missed treatments were associated with greater acute health-care use; transportation, weather, psychiatric illness, pain, and gastrointestinal symptoms were among associated barriers.	Association does not prove that any one barrier-removal intervention prevents hospitalization.
Transportation cohort, 2025: 115,982 patients in one large dialysis organization [5]	Transportation mode was associated with missed treatments and mortality; a reliable ride is a clinical access issue.	Illness, disability, and other confounding can influence both transport use and outcomes. A transport category is not a judgment about an individual.
Chenitz et al.: interviews with 30 patients; Sousa et al.: interviews with 24 patients [6,9]	Patient accounts identify transport, treatment burden, relationships, support, and competing demands that a laboratory dashboard misses.	Small qualitative samples explain experiences; they do not establish population prevalence or intervention effect sizes.
Liou-Johnson et al., 2026: convenience survey of 962 dialysis patients [7]	Social, cognitive, functional, and medication-access difficulties can overlap.	Cross-sectional self-report cannot establish causality or nationally representative prevalence.

Screening resources help teams ask consistently; they do not create housing, transport capacity, or appointment availability. The workflow proposed here is an evidence-informed practice approach. Its local value should be assessed by whether patients can obtain care and whether the barriers they identify become easier to manage.

For improvement work, track missed and shortened treatments with their reported reasons, completion of agreed actions, and the patient's assessment of whether help was useful. Separate hospitalization, dialysis elsewhere, rescheduled treatment, and unexplained absence. Count unavailable resources and failed handoffs as system gaps to address. Avoid claiming success from screening completion alone.

At the chair

Check safety. Ask what happened. Acknowledge the difficulty. Find the barrier. Agree on one workable next step. Follow through.

Use the companion N23 nursing card for the first conversation, escalation, and handoff. Revisit the plan after the next treatment; the goal is to make treatment possible while preserving trust and the patient's voice.

Related dialysis reviews

References

Sources reviewed September 29, 2026. Patient-study findings are distinguished from the practical workflow proposed here.