Mary is a 45 year old dialysis patient. She has been scheduled to come to the Seattle Clinic for dialysis 2 times per week for 3 years. Mary often misses her appointments and sometime will go 1-2 weeks without any treatment for her failing kidneys. When this happens, she will end up in the hospital with elevated potassium levels and too much fluid on her lungs and around her heart.
Mary is currently staying with a friend and sleeps on the couch in her friend’s apartment. Mary has periods of homelessness where she sleeps in the streets, sometimes she will get a housing voucher from her mental health case manager for a short stay in a local motel. Mary has a difficult time keeping up with her medications and her health is growing consistently worse as she misses her insulin and dialysis treatments. Her nutritional status is also poor and she struggles to maintain compliance with her diabetic dialysis diet.
Mary has 2 children. Her 7 yo daughter is in the custody of DSHS and her 14 yo son lives with Mary’s mother. Mary is able to see her son most any time, but has not been able to get to her mother’s home lately. Her social worker sets up times for Mary to have supervised visitation with her daughter.
As Mary’s dialysis social worker, you are putting together a biopsychosocial assessment for her. What additional information do you need to complete a full assessment? What questions do you have? What other disciplines do you need to consult or interview? Use the information above to begin your assessment of Mary.