A team of health care providers is integral to the care of chronic hemodialysis patients and includes nephrologists, social workers, dietitians, and nurses. Increasingly, the chronic hemodialysis population is composed of older patients with multiple comorbid conditions and reduced functional independence. The demands placed on social workers, nurses, and dietitians caring for the increasingly fragile chronic hemodialysis population have not been examined. We compared the interventions required by social workers, dietitians, and nurses caring for two demographically matched chronic hemodialysis patient groups undergoing dialysis in two outpatient units over a 6-month period to examine the demands imposed by these functionally dependent patients. Patients underwent dialysis in either a step-down unit or an ambulatory unit. Patients undergoing dialysis in the step-down unit had more coronary artery disease (6 of 12 patients [50%] versus 1 of 12 patients; P < 0.025) and peripheral vascular disease (6 of 12 versus 0 patients; P < 0. 004). Mean urea reduction ratio, hematocrit, and serum albumin values, as well as number of hospitalizations and mean days hospitalized for the 6-month study period, were not different between the groups. Patients undergoing dialysis in the step-down unit were more likely to have lower scores on activities of daily living (11 +/- 5 versus 15 +/- 3; P < 0.02), live in a nursing home (58% versus 8%; P < 0.01), be nonambulatory (66% versus 0%; P < 0. 01), and have a catheter as permanent dialysis access (66% versus 9%; P < 0.004). Significantly more social worker and dietitian time in hours per week were provided to the patients in the step-down unit (social workers, 259 versus 201 h/wk; P < 0.001; dietitians, 115 versus 96 h/wk; P < 0.001). Similarly, dialysis treatments requiring nursing interventions (treatments with hypotension, 36% versus 13%; obtaining blood cultures, 7% versus 2%; administering intravenous medications, 9% versus 2%; communicating with other health care providers, 3% versus 0.1%; and non-dialysis-related interventions, 5% versus 0.5%; all P < 0.005) were more common in the patients in the step-down unit. We conclude that increased dialysis provider care is required by patients who are functionally dependent and have increased comorbid conditions. The increased demands this fragile patient population places on dialysis providers must be recognized, examined more closely, and reimbursed appropriately.