Table 2.

Unmet Needs Themes, Subthemes, and Example Quotes

Subtheme	Patient Quote	Personnel Quote
Mobility
Mobility assessment	“I ended up falling and I couldn’t get up…. And I couldn’t reach my phone [so I waited] until she finally came into my room, she saw I was on the floor cause…when I fell I kind of like wrapped myself like a pretzel and I couldn’t get up.” (Man in his 70s with high IADL score)	“I just see them in the chair and you know, I have often times been surprised seeing them in some other part of the hospital and either they’re more active than I think they are or less active, so yeah, I do think that mobility, it’s certainly a concern.” (Nephrologist)
Transportation services	“Well, it’s okay. I had to stand my ground because they kept sending a van, but no lift and there’s 1 person can help me get up the van with the steps because she helps me good, but the other ones, no. The last one I had to have her 3 times and she just stands out there and I had to try to get on myself and then when I get on she’s driving like maniac, I mean really, like maniac. … the other day she told me, oh, you have to put your bags on because my back hurts. I said lady, I’ve been hurting more than that so come on.” (Woman in her 70s with low ADL score)	“So, they really don’t like waiting, when you schedule a trip it’s not as if they just come 30 minutes you know, like 2 minutes right before your ride comes they give you a window, you have to be ready in that window. So, say your dialysis appointment is at 12 o’clock but they need to come and pick you up at you know, 11:15. They have to be ready you know, a little earlier than what you might normally would be ready if someone is driving you, so that’s frustrating sometimes for patients. They will only blow the horn and wait 5 minutes … if the volume is low or they’re in the house they hear the horn you know, they can’t move as fast as they could when they were in their 30s to get to the you know, outside in time for the van… It will drive away.” (Social worker)
Medication
Appropriate prescribing	“And then so, you know when you go to urgent care and different places and you tell them your doctor he’s supposed to always get a report back …so I don’t know if he got it or not. All I know is he didn’t take me off it and I didn’t have sense enough to get off it.” (Woman in her 60s with high IADL score)	“…the med list at the dialysis unit is correct a small proportion of the time…. They have like 3 different med lists.” (Nephrologist)
Medication Management	“And my wife had to help me do it because my mind wasn’t functioning right, so I got my meds all mixed up and when I was supposed to take ‘em from the morning to the evening and stuff like that so she had to do ‘em for me.” (Man in his 70s with high IADL score) “I take this color and I take this little pill and that color and that big horse pill, you understand? So you know, at least I knew so now my only worry, I knew what pills to take, I just had to keep in my mind, have you taken your medicine today or not cause I didn’t want to take it twice.” (Woman in her 60s with high IADL score)	“The availability of medication, the cost in the elderly. I have a hard time at times, a patient who has Medicare as an elderly dialysis patient with some supplemental insurance where we basically struggle getting a [phosphorus] binder paid for.” (Nephrologist) “Being, I don’t know, my average patient is on 20 medicines or something like that and you know, we tell them to take 3 of 1 pill, 4 of another one at this and that time and you know, when we go and review their labs you know, we assume that they’re taking these and thus we need to increase or decrease the medicines, but the first question that needs to be assessed is whether really, are they really taking them…what their understanding of what they need [to take is].” (Nephrologist)
Social Support
IADL support	“…the things that when I’m at home that I’m not able to do any more and of course I’ve accepted it, but like for an example I can’t mow my grass or ride my mower or run my tiller and have a garden in my back yard.” (Man in his 80s with medium IADL score)	“so I have reported it to APS before if there’s some other issues going on in the home in which I feel like you know, a patient is being neglected or abused in any kind of way. We have to report that. And then sometimes it’s not necessarily a family member, it might be just a patient just not able to take care of themselves.” (Social worker)
Emotional support	“Yeah, and they don’t address that [death] in dialysis you know, they don’t have nobody - well I guess they had a social worker you can talk to, but it’s you know, and I guess the social worker will talk to you, but and I’m sure that some people do talk to the social worker about it cause it will affect different people different ways…and you try to be immune to it or get hard or hard core about it, it’s something’s that’s gonna happen you know, and I ain’t saying you get used to it, you don’t.” (Man in his 70s with medium IADL score)	“Patients may appear to be a little bit more solemn or depressed. Like I said, maybe they used to come in smiling and could laugh and joke but now they’re a little bit more quiet, they don’t smile as much, or a lot of times they will verbally say you know, I’m not sure how much longer I’m gonna be here. This just doesn’t feel right or they start saying their goodbyes or they start talking about death and making sure my family is okay and having those types of conversations with you in conjunction with you know, you can see a physical decline” (Social worker)
Communication
Patient-provider communication	“Well, see what happen is, you see, what he (nephrologist) does…he reads my report and the only thing he does is check to see if everything going as the prescription. You see, somebody gave him a prescription for what I was supposed to have done you know, and he base his thing on what you know, what’s going on you know. You see, most time, all he do is adjust my weight up and down…I guess he got to figure out…certain things you know, it’s just so quick. You know, cause he got a hundred some patients in here.” (Man in his 70s with high IADL score) “…The nurse ask you all the questions and the doctors (PCP) come in and look at you, you know, talk to you for 10 minutes and then he gone on to the next patient you know, so. … Yeah, well like I said, it change up so often, man you know, this is no longer you know, this is who your doctor is now you know, so the next time I go it may be somebody different. Who knows.” (Man in his 70s with medium IADL score)	“So for some of them it’s they have family that’s involved with their care but the family might be out of state. And so they actually aren’t necessarily seeing the condition of the patient. And so when you’re trying to communicate to have, say a care plan meeting because their cognitive abilities are declining. You know sometimes [that’s] hard you know to have those discussions because they’re not seeing the patient.” (Nephrologist)
Interprofessional communication	“The only thing that they’re (the PCP]) not getting is the lab work from [dialysis]. It doesn’t filter into the [medical record]. … I think that should be, cause I don’t want to be stuck here taking my blood, they’re taking it and then I go over there, and I actually will be stuck because they don’t have the feedback from [dialysis].” (Woman in her 70s with medium IADL score)	“so the primary care person…recently for instance [sent a message through the electronic medical record to] us about a med, but we don’t routinely know when the patient went to their PCP], because they don't… communicate with us you know, and frankly we don't communicate with them. I try to tell them when they tell me they're gonna go see this doctor, that doctor, I say well here, take your run sheet, it has all this good information on it …” (Nephrologist) “We can fax like lab results and treatment sheets and stuff like that to the doctors if they're requesting as long as they have the medical release but typically we don't.” (Nurse)

Abbreviations: ADL, activities of daily living; IADL, instrumental activities of daily living; PCP, primary care provider.