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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. 

In This Issue: 

According to, there are millions of children and families living in America facing hunger and food insecurity every day. Because of the coronavirus pandemic, it is estimated that more than 42 million people may experience food insecurity, including a potential 13 million children.

Network 8 and our Mississippi Medicaid staff participated in a virtual food drive benefiting the Mississippi Food Network during the month of September, providing 4,890 meals. We are grateful for the opportunity to give back.

Network 14 participated in a virtual food drive benefiting the North Texas Food Bank and was able to provide over 600 meals to the North Texas area.


The Kidney Donor Profile Index (KDPI) tells how long a deceased donor kidney is likely to function in the body. KDPI combines a variety of donor factors such as age, medical history, and other health components into a single number. Kidneys with a KDPI below 85 can last up to 15 years or longer, while kidneys with a KDPI above 85 may not last quite as long, but still give many years free of dialysis. High-KDPI and increased kidneys can be an option for some patients when medically appropriate.

CMS Goals:

  1. Increase patients added to the transplant waitlist
  2. Increase the number of patients receiving a kidney transplant


Understanding High-KDPI and Increased Risk Kidneys 

Network Contact:

Home Dialysis

It is important to educate patients not only about how dialysis will affect their health, but also their lifestyle. There are many things that patients must consider when deciding their treatment options. It is important to help patients know the benefits and drawbacks of each option.

CMS Goals:

  1. Increase the number of new ESRD patients utilizing home dialysis
  2. Increase the number of in-center patients moving to a home modality
  3. Increase the number of rural ESRD patients using telemedicine to access a home modality


Home Dialysis Central’s Treatments Compared

My Dialysis Choice (English and Spanish):

Network contact:

Hospital Admissions, Readmissions, and Emergency Visits

As we continue our efforts to decrease hospital admissions, this month we want to focus on reducing unplanned hospital readmissions. To learn how your facility readmission rates compare to other facilities within the Network and the US, see Table 4 of the Dialysis Facility Report for Fiscal Year 2022. If you have questions about this data, please reach out to Dany Anchia at the email address noted below.

CMS Goals:

  1. Decrease the national rate of hospital readmissions
  2. Decrease hospital 30-day unplanned readmissions
  3. Decrease the national outpatient emergency department visits​​​
Strategies to Improve Care Coordination and Reduce Avoidable Readmissions in Rural Hospitals


Network contact:


Pneumococcal disease is a name for any infection caused by bacteria called Streptococcus pneumoniae, or pneumococcus. Pneumococcal infections can range from ear and sinus infections to pneumonia and bloodstream infections. There are two vaccines used in the United States help protect against pneumococcal disease: Pneumococcal conjugate vaccine (PCV13) and Pneumococcal polysaccharide vaccine (PPSV23). Regular vaccinations can prevent many types of pneumococcal disease and the potential complications that may arise.

CMS Goals:

  1. Achieve patient COVID-19 vaccination rate of 80%
  2. Achieve patient influenza vaccination rate of 85%; achieve 90% of staff influenza vaccination
  3. Achieve patient pneumococcal conjugate 13 (PCV, Prevnar 13) vaccination rate of 56%
  4. Achieve patient pneumococcal polysaccharide (PPSV, Pneumovax 23) vaccination rate of 87%; achieve PPSV vaccination rate of 80% of patients over age 65
  5. Achieve patient PPSV booster vaccination rate of 43%


Pneumococcal Disease in Adults and the Vaccines to Prevent It

Pneumococcal Vaccination: Information for Healthcare Professionals

Network contact:

Patient and Family Engagement

Patient-to-patient peer mentoring can help improve outcomes for ESRD patients. Some studies describe the benefits of peer mentoring programs in dialysis to include: better goal setting, decision-making and more interest in managing their own care.  

Resource: Bennett PN, St Clair Russell J, Atwal J, Brown L, Schiller B. Patient-to-patient peer mentor support in dialysis: Improving the patient experience. Semin Dial. 2018 Sep;31(5):455-461. doi: 10.1111/sdi.12703. Epub 2018 May 2. PMID: 29722062.

CMS Goals:

  1. Increase the number of facilities that integrate patients and family members into QAPI meetings
  2. Assist patients to develop a life plan
  3. Develop and support a peer-mentoring program


QAPI: Help Patients Understand Their Role in Quality Assessment and Performance Improvement (QAPI)


Life Plan/Care Plan: My Plan, My Care

Peer Mentoring: Podcast - Benefits of Peer Mentorship  

Network contact for Patient & Family Engagement (Life Plans and QAPI):

Network contract for Peer Mentoring:


Mental Illness Awareness Week is October 3-9; National Depression Screening Day is October 7; and October 10 is World Mental Health Day. The National Institute of Mental Health reports adults with a medical illness are more likely to experience depression.

CMS Goals:

  1. Increase the number of patients accurately screened and treated by a mental health professional for depression
  2. Ensure that facilities report depression screening in EQRS


The National Institute of Mental Health has a variety of resources related to chronic illness and depression. Click HERE to learn more. They also have a downloadable booklet called “Chronic Illness and Mental Health: Recognizing and Treating Depression.” Click HERE to download a copy.   

Network 8 Contact:

Network 14 Contact:

EQRS Data Quality

CMS Forms

Based on a baseline calculated for each network service area, there is a performance target for the CMS quality initiative related to EQRS data.

The three measures that CMS has assigned to facilities and networks to focus on are:

  • Timeliness of CMS 2728 forms (within 45 days)
  • Timeliness of CMS 2746 forms (within 14 days)
  • Timely submission of admissions (within 5 days)

It is important to understand that these performance measures are being continually monitored by CMS and the Network.

Also, please note that the only way to improve your score in a performance area is by making timely submissions in the future.

When looking at the EQRS dashboard, you will see forms submission information for your facility.


On the dashboard, the 2728 forms are broken up into three categories: New, Due, and Past Due.

  • Forms in New are less than 10 days old. Forms in Due are less than 45 days old. The 2728 forms submitted from the New and Due categories count toward improving your facility’s score.

The 2746 forms are broken up into two categories: Due, and Past Due.

  • CMS 2746 Forms in the Due category count toward improving your facility’s score.

Looking at the dashboard whenever you log into EQRS will help you stay on track with the forms that are New or Due.

  • Remember this: New and Due help your score.

CMS Goals:

  1. 2% increase in rate of admission records from dialysis facilities entered within 5 days
  2. 2% increase in rate of initial 2728 forms submitted from dialysis and transplant facilities within 45 days
  3. 2% increase in rate of 2746 forms submitted from dialysis facilities within 14 days


Click HERE to download the October 2021 EQRS newsletter.

Network 8 Contact:

Network 14 Contact:


Visit or for more information. Produced under CMS contract numbers: 75FCMC19D0005-75FCMC21F0001 and 75FCMC19D0005-75FCMC21F0002.

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