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:
“The first step towards getting somewhere is to decide you’re not going to stay where you are.” — J.P. Morgan
Happy New Year! We hope you are off to a great start to 2023! We continue to work diligently to improve outcomes for each contract goal below. If your facility is struggling with any of these areas and you would like one-on-one assistance, please reach out to the task area contact. We are here to help!
News you can use:
- The Forum of ESRD Networks Medical Advisory Committee has updated the Infection Control Communication Form Between Nursing/Personal Care/Assisted Living Facility and Dialysis Facility. Download Updated Form
- The ESRD NCC has released the Decreasing Dialysis Patient-Provider Conflict (DPC)—December 2022 Addendum. The addendum builds on the work of the original and successful DPC toolkit and includes four new modules. The DPC Addendum can be found on the ESRD NCC website on the Professionals page under the Patient Engagement accordion. Download Addendum
Behavioral Health
EQRS depression screening and treatment data are provided to Networks monthly. The report indicates whether follow-up treatment is planned for patients screening positive for depression, along with Medicare claims data for outpatient mental health treatment.
Remember to follow up with those who screen positive for depression and follow a well-developed plan to encourage the patient to seek mental health treatment. Also, don’t forget that Primary Care for Mental Health Services and telehealth are good follow-up options for patients who screen positive for depression.
Resource: Depression Zone Tool
Behavioral Health Contact: ericka.webb@allianthealth.org
Home Dialysis
Has your facility utilized the benefits of self-care in-center dialysis? Did you know the government offers financial incentives to facilities with patients doing self-dialysis in-center as part of the ETC model?
Your facility can take small steps towards helping your patients feel empowered to take their own care while they are in-center, and you can use this approach as a stepping stone towards home dialysis.
Self-care in-center dialysis offers many benefits for your staff and your patients. It helps patients become more empowered, aware of their own care, and have better health outcomes. Check out the articles below to learn more about the advantages of using self-care in-center and the financial benefits.
Resources:
Home Dialysis Contact: maryam.alabood@allianthealth.org
Hospital Admissions, Readmissions and Emergency Visits
In December, we hosted an initial Brainstorming Open Office Hours session with selected facilities for hospitalization measures.
Thank you to those who attended and provided such great feedback. Below are some resources the Network compiled to address common barriers identified by meeting participants.
Missed Treatments:
RX and Transportation Assistance Funds:
Transportation Assistance:
RX Discounts:
Discharge Planning:
Make Dialysis Fun Ideas:
Hospitalization Contact: sheila.mcmaster@allianthealth.org or mary.albin@allianthealth.org
Transplant
Patients who received a kidney transplant can serve as powerful and trusted transplant advocates. They can ease other patients’ fears by answering questions, providing guidance and emotional support, and sharing their transplant experience.
Connecting with someone who received a transplant can be a positive life-changing experience. We invite transplant recipients to speak with patients or join lobby days. Review the NCC’s Transplant Trailblazer Program guide with your staff to learn how your facility can implement a transplant patient peer program.
Resource: Transplant Trailblazer
Transplant Contact: arlandra.taylor@allianthealth.org
Vaccinations
In August 2022, CMS released a modified vaccination reporting process in EQRS. EQRS users must enter any new vaccination data for Hepatitis B, Influenza, and Pneumococcal vaccinations on the Manage Patient screen under the new Vaccinations tab. This new EQRS reporting process for vaccinations is event-based. EQRS users must submit vaccination data when a vaccination event occurs. A vaccination event occurs when a patient:
- Receives a vaccine dose administered by the reporting facility.
- Receives a vaccine dose from an outside provider with documentation.
- Receives a vaccine dose that is self-reported with or without documentation.
- Does not receive a vaccine dose offered by the reporting facility.
In addition to reporting vaccination information when a vaccination event occurs, facilities must also review patient vaccination history and enter any confirmed vaccination information in EQRS upon each patient’s admission to the facility. For additional information about the new EQRS reporting process for vaccinations, refer to the EQRS Vaccination Data Submission Requirements and Frequently Asked Questions.
CMS Goals:
- Achieve patient COVID-19 vaccination rate of 80%.
- Achieve patient influenza vaccination rate of 90%; achieve 90% of staff influenza vaccination.
- Achieve patient pneumococcal conjugate 13 (PCV, Prevnar 13) vaccination rate of 56%.
- Achieve patient pneumococcal polysaccharide (PPSV, Pneumovax 23) vaccination rate of 87%. Achieve a PPSV vaccination rate of 80% of patients over age 65.
- Achieve patient PPSV booster vaccination rate of 43%.
Vaccinations Contact: kristi.durham@allianthealth.org
Patient and Family Engagement
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CMS expects facilities to invite their patients to the monthly facility Quality Assurance and Performance Improvement (QAPI) meeting. This meeting has different names depending on the dialysis organization, such as the TQM, FHM, or QAI meeting. Whatever the name, CMS expects patients to be invited every month. Note: The QAPI meeting is NOT the monthly plan of care meeting held with patients to discuss their health outcomes.
Many facility social workers and facility administrators/clinical managers have expressed concern to the Network about patient involvement during parts of the meeting dedicated to confidential topics. To offset this concern, the Network recommends that facilities invite patients to attend for a short period and allow them to voice their suggestions/comments/concerns to facility leadership. If patients do not have any feedback, this would be a great time to introduce what the Network is, what CMS/Network Quality Improvement Projects your facility is participating in, and how the facility is meeting the project goals. Another way to engage patients during the QAPI meeting is to inform them of ways they can volunteer to assist their fellow patients or discuss barriers that impede volunteering.
If your facility is still following COVID protocols or if the patient does not have a way to attend the meeting in person, consider allowing the patient to attend via conference call or via submission of written comments/suggestions for meeting attendees to review and address. Make sure to provide feedback to the patient in a timely manner once the QAPI meeting is over if the patient provides their information in a written format.
Network staff and Medical Review Board representatives are creating a QAPI topic list to assist facilities and patients during the monthly meetings. We aim to complete and distribute the list within 30-45 days.
For questions or concerns about meeting this CMS expectation, please contact Debbie O’Daniel.
Patient and Family Engagement Contact: debbie.odaniel@allianthealth.org
EQRS News You Need to Know
Completing the CMS 2746 Form (the CMS death notification form)
One area of significant improvement that’s needed Network-wide is the timely submission of the CMS 2746 form.
Achieving Compliance: The best way to achieve compliance with the CMS requirements for the 2746 form is to check your dashboard for missing forms every week (at a minimum). However, if you have not updated the demographic page with death information, there will be no dashboard prompt for the form.
Due Date: The CMS 2746 form is due for all permanent patients who died within the last 30 days of being treated in your facility. Your facility is responsible for the form even if the patient discontinued or went to the hospital and they died within 30 days of being discharged from your facility.
Cause of Death (COD): If you don’t know COD when the form is due, submit the form on time with the best available information (remember, you can use 99 for unknown and 29 for cardiac arrest (cause unknown)). Also, the unlisted code for COVID-19 is 105.
Tips, Tricks, and Traps: The COD and Date of Death (DOD) are not entered directly on the 2746 form. Instead, they are entered on the patient demographic page in EQRS. When entering the COD and DOD, you must enter the DOD as the Effective Date. EQRS defaults to today but will not accept an entry where the effective date is after the DOD.
Resource: EQRS Quick Start Guide
Network 8 and 14 Service Ticket Request:
https://bit.ly/ESRDServiceTicketRequest
EQRS Contacts:
robert.bain@allianthealth.org or sade.castro@allianthealth.org
