Plans of Care


In § 494.90 of the ESRD Conditions for Coverage, the Interdisciplinary Team, as defined at § 494.80, is required to develop a plan of care (POC) for each patient, which must address, but not be limited to, the following:

  • Psychosocial status
  • Modality (including home dialysis and transplantation status)
  • Rehabilitation status

Patients have the right to be included in their POC meetings if desired. The POC meeting provides an opportunity for the patient to learn about ESRD and to communicate his/her wants and concerns about treatment to the team. 

Resources

Council of Nephrology Social Workers (CNSW) Care Planning Resource Toolkit
Florida ESRD Network (Network 7) What's Your Plan brochure
University of North Carolina's My Dialysis Plan program