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:
“Without Valentine's Day, February would be, well, January.” — Jim Gaffigan
Happy Valentine's Day, everyone!
This month, the Centers for Medicare & Medicaid Services Office of Minority Health (CMS OMH) celebrates American Heart Month and Black History Month. According to the Centers for Disease Control & Prevention (CDC), one person dies every 34 seconds from heart disease, the leading cause of death for men, women, and most racial and ethnic groups in the United States. Black communities are often disproportionately affected by heart disease and many of its risk factors based on certain social determinants of health, including access to medication, preventive services and safe exercise. The CMS OMH hopes to highlight the importance of heart disease prevention and care management to combat health disparities in Black communities, which often have an increased risk of cardiovascular disease (CVD).
News you can use:
Though heart disease-related deaths have declined over the past two decades, research shows that disparities persist as Black adults experience higher death rates than white adults, especially in rural or segregated areas. Black people also have the highest prevalence of cardiovascular disease out of all racial groups in the United States, with 58.8% of Black females and 60.1% of Black males having some form of CVD from 2015 to 2018. Click here to access OMH resources.
Also related to American Heart Month, the CDC has some great tools and resources for patients to use to help take control of their high blood pressure. You can find the toolkit on the CDC website here. The Network also has a one-page patient education resource addressing how patients can maintain a healthy heart. You can find the handout in both English and Spanish on the Network’s website.
Look under the Monthly Patients Education Flyers section; PFE February Handout.
All direct care staff should be aware of their patients' health equity and health disparities. We serve a population that may have never interacted with a trusted team of health professionals. Many of us have family members who have experienced intimidation in the health care setting due to health disparities.
Take the opportunity to learn how to effectively work with every patient to ensure they obtain the best possible outcomes. We are charged to meet them where they are, going the extra mile to ensure our patients experience health care that strives to fully meet their needs.
Behavioral Health Contact: firstname.lastname@example.org
The Medical Education Institute has released a new video to help patients choose a kidney failure treatment. The animated video also highlights the My Kidney Life Plan, a resource that helps patients choose a treatment by evaluating what matters most to their lifestyle.
Home Dialysis Contact: email@example.com
Hospital Admissions, Readmissions and Emergency Visits
December data analysis for both Network 8 and Network 14 revealed three common diagnoses for hospital admission and readmission: sepsis, hyperkalemia, and fluid overload. For emergency department visits, the most common causes were chest pain, vascular access bleed and hyperkalemia.
Since hyperkalemia was noted for all three hospital measures, we have provided patient and staff resources to add to your toolbox. Vascular access dysfunction information for staff is included below as well.
Hospitalization Contact: firstname.lastname@example.org or email@example.com
After Transplant is one of four interactive education courses from the National Kidney Foundation’s Kidney Learning Center. After Transplant provides information and tips on what to expect after receiving a kidney transplant. Patients and family members will learn about medications, organ rejection, mental health, and practical considerations for patients and care partners.
This free new curriculum is divided into 15 short courses that can help patients learn what to expect and identify potential challenges. Share these short online courses with your patients and help them get signed up to learn more about transplant.
Transplant Contact: firstname.lastname@example.org
Do you need to complete continuing education hours or want to learn more about vaccination requirements? You Call the Shots is an interactive web-based immunization training course that includes the latest guidelines and recommendations in vaccine practice.
Click here to learn more about You Call the Shots and view the modules that discuss vaccine-preventable diseases.
Vaccinations Contact: email@example.com
Patient and Family Engagement
Is being a patient advocate important to you? Do you believe it is essential for patients and caregivers to be involved in their care?
The Network needs YOU to help us collaborate and brainstorm ideas, resources, and new ways to get kidney patients, family members, and dialysis facilities involved in patient and family engagement. We are looking for engaged individuals who are passionate about patient and family involvement.
We are looking for professionals in the kidney community that can help us make a significant impact. If you are a physician, surgeon, facility manager, social worker, regional leader, PCT, administrative assistant, patient, family member, or caregiver, your expertise will benefit this group.
The Patient and Family Engagement (PFE) Coalition’s goals are to increase the number of patients attending facility QAPI meetings, increase the number of patients who create a life plan/goals, and increase the number of patients to become mentors to their fellow patients.
The coalition meets virtually once a quarter for 30 minutes. If you are interested in joining the PFE Coalition, please complete our PFE Coalition Interest Form. If you know someone who would be a good fit for the PFE Coalition, please share this information.
Patient and Family Engagement Contact: firstname.lastname@example.org
EQRS News You Need to Know
Completing the CMS Form 2744 (ESRD Facility Survey)
What is it? A report that captures a limited amount of information about a dialysis or transplant facility’s operations for a calendar year.
Which facilities must complete the report? Every facility approved by Medicare to provide services to ESRD patients must furnish the information requested.
When is it due? The CMS 2744 deadline is established by each Network. The facility deadline for completion is March 31. This means the CMS 2744 is submitted without errors, and comments are being made for any warning by March 31.
If my facility was only certified for part of the year, do I still need to complete the CMS 2744? Yes, if your facility was certified at any point during the calendar year covered by the CMS 2744, your facility must complete a 2744. So, if your facility closed during the calendar year or was certified during the calendar year being reported on the CMS 2744, you must complete the ESRD Facility Survey.
How is the information on the CMS 2744 captured? The CMS 2744 is generated (by the facility) in EQRS based on the data that the facility submitted to EQRS. The 2744 module of EQRS reviews the submitted data and generates the report information for all but a couple of fields. Dialysis facilities must provide the number of incenter dialysis treatments (this includes transient patient treatments and any training treatments provided at the facility for home hemodialysis patients but does not include treatments for AKI patients) and the number of staff as of the end of the year. Transplant facilities must provide the number of patients on the waitlist and how many of those patients are currently on dialysis, and how many are not on dialysis.
How is the CMS 2744 reviewed? When a facility submits the CMS 2744 for review, the form is placed in the ESRD Network’s queue. ESRD Networks have 30 days to review the CMS 2744 from its submission. Generally, depending on how many forms have been submitted, a review is conducted within 14 days of submission.
What is being reviewed? ESRD Network staff are looking at several key pieces of information in their review of the CMS 2744.
- Who submitted the ESRD Facility Survey, and when the CMS 2744 was submitted?
The survey needs to be generated by someone who represents the facility. Some corporations have CMS 2744 teams to assist or to complete the ESRD Facility Survey. (If a corporation designates that only certain users may submit the CMS 2744, then we will not accept a form generated by other users.) Unless the facility is permanently closed during the calendar year, the survey must be generated after the calendar year is over. There is usually a lag in data being available to EQRS, and there are usually some updates each year to the CMS 2744 module in EQRS. So, as a practical matter, we want to ensure the form is generated late enough to capture all relevant data and updates.
- Are the Treatment and Staffing numbers entered, and are they in range for the facility?
We look at the treatment numbers you provide on the report (fields 37 and 38). We can estimate the number of treatments based on the number of patients (and their modalities) you have in your facility. If your treatment numbers fall outside our estimate range, we will not accept your form without further explanation. There are occasions where a facility may have a higher or lower number of treatments that facilities should provide an explanation for. If a facility closed for part of the year, the treatment number may be lower than expected. Also, if you provided treatments for a sister facility that was closed for a portion of the year, your treatment numbers may be higher than we expected.
- Are there any Errors or Warnings that have not been addressed by a comment?
There are two types of system responses provided by the CMS 2744 module of EQRS: Errors and Warnings. Errors begin with the word “Error:” and warnings are indicated as “Warning:”.
The ESRD Network generally will not accept a CMS 2744 with any errors. Submitting a form with an error on it slows the process for acceptance. Once a form is submitted to the ESRD Network for review, facility users cannot edit the form. The ESRD Network must review the form and reject or accept it. If it has an error, it will not be accepted. Please don't continue to submit a CMS 2744 that the ESRD Network has rejected without resolving all of the errors on the form. Also, a comment must be provided for warnings on the CMS 2744.
Remember: Resolve errors and comment on warnings.
What are the most common reasons a CMS 2744 is rejected? The most common reason a CMS 2744 is rejected is unresolved errors. If the form has an error designated by the EQRS 2744 module, it will not be accepted.
Treatment numbers out of range is the second most common reason for rejection. For field 37, we expect to see treatment numbers within a certain range. The most frequent issue with this field is entering the number of patients rather than treatments. If a patient receives three treatments a week times 52 weeks, that’s 156 treatments. So, while we don’t expect to see 156 treatments per patient, we certainly expect to see more than one. For field 38, we are looking for the number of training days provided to PD patients. So, if you don’t have PD patients, don’t put anything in field 38. If you do, put only training days. Do not put exchanges.
The third most common reason is related to staffing. The CMS 2744 module does not generate a warning or error for staffing, but it is reviewed by the ESRD Network. We expect an entry for each position type identified on the CMS 2744 in the Conditions for Coverage. So, we look for RNs, Social Workers, and Dietitians. The staffing levels are based on the end of the survey period (December 31). Full-time staff works at least 32 hours per week for the clinic. Part-time staff works less than 32 hours per week for the clinic. If a contractor provides services, they are still counted in the staffing categories. If your clinic has vacant positions at the end of the year, they are reported in the Open positions column (either as Full Time Open Positions or Part Time Open Positions).
How do I know the Network has reviewed my form? When Network staff review a 2744, an email is sent to the contact identified in our system. We try to include the person who submitted the form, but we do not always know who that is. The USER ID of the last person to generate the CMS 2744 is on the form, but it is sometimes cryptic, and we may be unable to determine who it is and what their email address is. The email includes the new status of the form and a description of our review findings. We generally identify findings based on the field numbers on the form. We also put a brief comment in the reason field that you can see if you look up your CMS 2744 Status Change Updates. But a fuller explanation is provided in the email we send you.
Do I need to get an appointment? An appointment is not generally required. We will recommend an appointment if we believe that is the most efficient way to assist you. We will only require an appointment if your CMS 2744 has been submitted numerous times, and it appears that the instructions and feedback provided are insufficient to aid you in submitting an ESRD Facility Survey that we can accept. If you have difficulty resolving errors, you can schedule an appointment. If you are submitting a CMS 2744 for the first time and you want to be sure that you’re doing it right, please feel free to schedule an appointment. Appointments are made through this website: https://booknow.appointment-plus.com/9e0k79v2/.
Go to that website and choose CMS 2744 Annual Survey Report Review as the appointment type. Then select a representative (either Sadé Castro or Robert Bain). Then pick an available date and then book the appointment time. All times listed are Central Time. We provide support to three different time zones, so please be sure to adjust if you are not in the Central Time Zone.
We will call you at your appointment time at the phone number you provide. If we can’t reach you, we will email you at the email address you provide.
Network 8 and 14 Service Ticket Request:
email@example.com or firstname.lastname@example.org