Table 3.

Patient-Identified Priorities, Responsive Action Items, and Responsible Parties

Patient Priority	Responsive Action Item(s)	Responsible Party
Increase energy level	Refer to cardiologist, change dialyzer size, monitor Kt/V	Nephrologist
Address anxiety and forgetfulness	Refer for neuropsychological evaluation, prescribe antidepressant and monitor effects	Nephrologist and nurse
Eat more diverse foods	Discuss alternative protein options that: (1) improve appetite and (2) fit within patient budget to ensure sustainable provision	Dietitian and social worker
Spend more time at home	Schedule home dialysis education class	Social worker
Obtain eyeglasses	Refer to ophthalmologist to update prescription, confirm insurance benefits	Nephrologist and social worker
Maintain independence	Refer to vocational rehabilitation services, follow up on status of transplant evaluation	Social worker
Attend monthly family gatherings	Communicate family gathering schedule to care team, modify treatment start time or day of week to facilitate attendance	Patient and nurse
Play piano	Refer to hand specialist for pain and numbness in left hand	Nephrologist