This ESRD facility monthly newsletter highlights the latest ESRD insights and resources. Our goal is to provide you with a resource that makes it easy for you to stay on top of trends and support you in providing the best possible care for those you work with and serve.
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In This Issue:
- News You Can Use
- CLAS
- Home Dialysis
- Hospital Admissions, Readmissions and Emergency Visits
- Transplant
- Vaccinations
- Patient and Family Engagement
- EQRS
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“In early June the world of leaf and blade and flowers explode, and every sunset is different”
—John Steinbeck
After careful consideration, we have changed our newsletter distribution schedule to every other month. The next newsletter will be delivered to your inbox in August. Until then, we are only an email or phone call away.
The contacts for the QI activities are listed in each section below. In addition:
- Network 8 general inquiries can be sent to nw8info@allianthealth.org.
- Network 14 general inquiries can be sent to nw14info@allianthealth.org.
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News You Can Use
Network 8 partnered with Tennessee, Alabama and Mississippi’s health departments and Project Firstline to promote infection prevention education in dialysis settings. Nurses, technicians and other staff are invited to participate in four brief modules outlining basic IPC practices. Each module also provides 0.25 CEUs. If you are interested in participating, complete the following survey: https://redcap.link/PFL_dialysis_education. Network 14 facility staff can access Project Firstline modules directly here.
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CLAS
Cultural and Linguistically Appropriate Services (CLAS) ensure that services provided are respectful and responsive to each patient’s cultural and individual needs. The federal CLAS standards provide 15 guiding principles to ensure that your facility meets the needs of your patients with health disparities. Failure to address health disparities could lead to increased hospital admissions, poor treatment and/or medication adherence, higher infection rates, lower vaccination rates, and increased disruptive behavior, all of which may impact transplant eligibility. Two CLAS resources have been provided this month to help you learn more about this CMS priority.
Resources:
Resources:
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Home Dialysis
As we move into the third year of our five-year contract with CMS, the goals for home dialysis have gotten steeper. This year, we are tasked with a 30% increase over baseline in the number of patients who begin dialysis on a home modality on day one (incident) and a 12% increase over baseline in the number of patients transitioning from in-center to a home modality (prevalent). As we begin our improvement efforts for this contract cycle, we want to ensure you have access to the Home Dialysis Change Package. If your monthly facility report card indicates that improvement is needed, the change package is a great starting point!
Home Dialysis Contacts:
Network 8:katherine.buntin@allianthealth.org
Network 14:grace.robbins@allianthealth.org
Network 8:katherine.buntin@allianthealth.org
Network 14:grace.robbins@allianthealth.org
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Hospital Admissions, Readmissions and ER Visits
The Network has kicked off Option Period 2, which is the third year of our five-year contract for “Reducing Hospitalizations” quality improvement activities. The Network goals for Option Period 2 are to reduce patient emergency department visits, unplanned hospital admissions, and 30-day hospital readmissions by 4% overall. The Network can only measure progress in our Medicare Fee for Service (FFS) population based on submitted Medicare FFS claims data. Thus, your internal hospitalization rate may not match the data the Network obtains.
Patients missing treatments is one key area identified by our hospitalization coalition as a primary driver of hospitalizations that can be addressed with strategies and interventions. Implementing a facility protocol for addressing patients missing treatments is a highly effective practice and can reduce unnecessary hospitalization. In the next few months, the Network will introduce a “Don’t Play Games with Your Health” campaign to address the barriers patients face that can lead to missed treatments.
In the meantime, your internal protocol may include the following:
Patients missing treatments is one key area identified by our hospitalization coalition as a primary driver of hospitalizations that can be addressed with strategies and interventions. Implementing a facility protocol for addressing patients missing treatments is a highly effective practice and can reduce unnecessary hospitalization. In the next few months, the Network will introduce a “Don’t Play Games with Your Health” campaign to address the barriers patients face that can lead to missed treatments.
In the meantime, your internal protocol may include the following:
- Have the patient speak with the charge nurse and clinic manager when they miss or call to say they will not be there for treatment.
- Offer a later chair time and move a later patient up earlier to accommodate the patient.
- Keep a chair open for extra treatments if possible.
- Educate patients regularly on the effects of missing treatments.
Hospitalization Contacts:
Network 8:kristi.durham@allianthealth.org
Network 14: koby.guthrie@allianthealth.org
Network 8:kristi.durham@allianthealth.org
Network 14: koby.guthrie@allianthealth.org
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Transplant
Black Americans have a prevalence of chronic kidney disease that is 25% higher than white Americans, are 10 times more likely to develop hypertension-related kidney failure and almost four times more likely to develop kidney failure. Linked by Love is a fictional story that uses drama and comedy to address the Black population's unique cultural barriers and significant medical disparities. Watch Beverly and her family handle her kidney disease, dialysis treatments and transplant.
Transplant Contact: arlandra.taylor@allianthealth.org
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Vaccinations
COVID
The federal Public Health Emergency for COVID-19 expired on May 11, 2023. As a result, there were changes to the National Healthcare Safety Network (NHSN) reporting by dialysis facilities beginning on May 12, 2023.
The federal Public Health Emergency for COVID-19 expired on May 11, 2023. As a result, there were changes to the National Healthcare Safety Network (NHSN) reporting by dialysis facilities beginning on May 12, 2023.
Expired Centers for Medicare and Medicaid (CMS) Requirement:
CMS no longer requires dialysis facilities to report COVID-19 cases and deaths among patients and staff to NHSN. The last week for dialysis facilities to report COVID-19 cases and deaths to NHSN was May 3- 9, with a submission deadline of May 10.
Required Vaccination Reporting after May 11, 2023:
Reporting of COVID-19 vaccination among patients and staff is required. Dialysis facilities should continue reporting to NHSN’s Patient COVID-19 Vaccination and Healthcare Personnel COVID-19 Vaccination modules. However, facilities only need to report COVID-19 vaccination data for patients and staff for the last week of each month.
For more information about reporting COVID-19 vaccination among patients and staff, visit the following webpages: Pneumococcal Vaccination
On May 24, all Network facilities were provided with the most recent CDC Pneumococcal Vaccine Timing guide for adults 19 to 64 years old with specified immunocompromising conditions and an educational flyer discussing common pneumococcal myths and facts. Please review these resources. Also, review your patients’ vaccination records to ensure they are current.
CMS no longer requires dialysis facilities to report COVID-19 cases and deaths among patients and staff to NHSN. The last week for dialysis facilities to report COVID-19 cases and deaths to NHSN was May 3- 9, with a submission deadline of May 10.
Required Vaccination Reporting after May 11, 2023:
Reporting of COVID-19 vaccination among patients and staff is required. Dialysis facilities should continue reporting to NHSN’s Patient COVID-19 Vaccination and Healthcare Personnel COVID-19 Vaccination modules. However, facilities only need to report COVID-19 vaccination data for patients and staff for the last week of each month.
For more information about reporting COVID-19 vaccination among patients and staff, visit the following webpages: Pneumococcal Vaccination
On May 24, all Network facilities were provided with the most recent CDC Pneumococcal Vaccine Timing guide for adults 19 to 64 years old with specified immunocompromising conditions and an educational flyer discussing common pneumococcal myths and facts. Please review these resources. Also, review your patients’ vaccination records to ensure they are current.
Vaccination Contacts:
Network 8:kristi.durham@allianthealth.org
Network 14: koby.guthrie@allianthealth.org
Network 8:kristi.durham@allianthealth.org
Network 14: koby.guthrie@allianthealth.org
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Patient and Family Engagement (PFE)
CMS expects ESRD Networks to have a 5% increase each contract year of facilities that successfully develop and support a Patient-to-Patient Support Program. The Network can assist you with developing peer mentors at your facility. Some facilities had peer mentor campaigns during lobby days or created bulletin boards with information. In the resource section below, you will find additional information about peer mentoring and virtual support groups to share with your patients.
Thank you to Karyl Spillman and the team at FKC Opelika Dialysis for sharing their creative bulletin board display (pictured above) to attract interest in becoming a peer mentor.
If you successfully obtained a peer mentor and would like to share your processes with other facilities, please contact Casey Rich or Debbie O’Daniel.
Resources:
- ESRD NCC Peer Mentoring Program
- National Kidney Foundation (NKF)
- Dialysis Patient Citizens (DPC) – meets on the second Tuesday of the month at 3 p.m. EST. Dial 866-808-5953, meeting code 253 841 3353
- Renal Support Network
Patient and Family Engagement Contacts:
Network 8: casey.rich@allianthealth.org
Network 14: debbie.odaniel@allianthealth.org
Network 8: casey.rich@allianthealth.org
Network 14: debbie.odaniel@allianthealth.org
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EQRS
Understanding the Timeliness Measurements for the Initial CMS 2728 and the CMS 2746 Form
The Initial CMS 2728 form is due within 45 days of the date the patient begins dialyzing in your facility. (If a patient initially receives a preemptive transplant, then the due date is calculated from the date of the transplant.)
You have six weeks and three days to complete a 2728. In looking at the last year of submitted 2728 forms, most CMS 2728 forms are due on Thursday. That’s because most patients (22%) start on a Monday. The on-time percentage for the initial 2728 is about the same for each day of the week. However, on average, 33% of the forms are due on the weekend (which has the lowest on-time percentage). Please be mindful of this and ensure forms are submitted before the due date if the due date falls on a Saturday or Sunday.
The CMS 2746 is due within 14 days of the patient’s date of death. Therefore, for example, if a patient dies on a Tuesday, then the form is due by the second Tuesday after death. Check your EQRS Dashboard routinely (every day is best) for missing forms. Also, when you’re looking ahead, be sure to factor in the weekend.
The Initial CMS 2728 form is due within 45 days of the date the patient begins dialyzing in your facility. (If a patient initially receives a preemptive transplant, then the due date is calculated from the date of the transplant.)
You have six weeks and three days to complete a 2728. In looking at the last year of submitted 2728 forms, most CMS 2728 forms are due on Thursday. That’s because most patients (22%) start on a Monday. The on-time percentage for the initial 2728 is about the same for each day of the week. However, on average, 33% of the forms are due on the weekend (which has the lowest on-time percentage). Please be mindful of this and ensure forms are submitted before the due date if the due date falls on a Saturday or Sunday.
The CMS 2746 is due within 14 days of the patient’s date of death. Therefore, for example, if a patient dies on a Tuesday, then the form is due by the second Tuesday after death. Check your EQRS Dashboard routinely (every day is best) for missing forms. Also, when you’re looking ahead, be sure to factor in the weekend.
Resources:
- June 2023 EQRS Town Hall Event - Register Here
- Network 8 and 14 Service Ticket Request
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Our mailing address is:
Alliant Health Solutions
400 Perimeter Center Ter NE
Suite 250
Atlanta, GA 30346
Our mailing address is:
Alliant Health Solutions
400 Perimeter Center Ter NE
Suite 250
Atlanta, GA 30346