2011 Heartland Kidney Network Annual Report TABLE OF CONTENTS... 1 A LETTER FROM THE BOARD PRESIDENT... 4 INTRODUCTION... 5

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1 Annual Report End-Stage Renal Disease (ESRD) etwork, etwork Coordinating Council, Inc. DBA: Heartland Kidney etwork CMS Contract umber: HHSM-5--WC 736 W Tiffany Springs Pkwy, Suite 3 Kansas City, MO Phone Main Fax Data Fax

2 Heartland Kidney etwork Annual Report Table of Contents TABLE OF COTETS... A LETTER FROM THE BOARD PRESIDET... 4 ITRODUCTIO... 5 ETWORK DESCRIPTIO... 5 POPULATIO DEMOGRAPHICS... 5 POPULATIO TABLES... 6 ESRD POPULATIO DEMOGRAPHICS... 7 Incidence... 7 Dialysis Prevalence by Modality... 8 Transplant... 9 Deaths... ETWORK STRUCTURE... CORPORATE DESCRIPTIO... History... etwork Coordinating Council... Mission, Vision & Core Values... 3 Board of Directors... 3 STADIG COMMITTEES AD RESPOSIBILITIES... 4 Executive Committee... 4 Audit/Finance Committee... 5 Governance Committee... 5 Patient Advisory Committee... 5 Fistula First/FFBI Committee... 6 Grievance Committee... 6 Quality Agenda Committee... 6 Transplant Evaluation Committee... 6 MEDICAL REVIEW BOARD MEMBERSHIP... 8 BOARD SUBCOMMITTEE MEMBERSHIP... 9 Standing Committees... 9 HEARTLAD KIDEY ETWORK STAFF... Heartland Kidney etwork Staff Members and Position Descriptions... Administration... Quality Improvement... 3 Community Information & Resources... 4 Information Management... 5 CMS ATIOAL GOALS AD ETWORK ACTIVITIES... 5 CMS GOAL #... 7 QUALITY MEASURES... 8 Fistula First Breakthrough Initiative (FFBI)... 8 Cannulation Training Kit... 8 Draft submitted: May 5,

3 Heartland Kidney etwork Annual Report Annual Facility Scorecards... 8 Lab Data Collection... 9 etwork-specific Goals... 9 QUALITY IMPROVEMET PROJECTS ACTIVE DURIG... 3 PATIET SAFETY AD BEEFICIARY PROTECTIO Diamond Patient Safety Program etwork Emergency Preparedness CMS GOAL # IDEPEDECE QUALITY OF LIFE VOCATIOAL REHABILITATIO TRASPLAT IMMUIZATIO CMS GOAL # PATIET PERCEPTIO OF CARE Patient Advisory Committee (PAC) etwork Patient Representatives (PR)... 4 PATIET EDUCATIOAL RESOURCES AD MEETIGS... 4 Patient ewsletter-heartland Headlines... 4 Patient Meetings... 4 COMPLAITS GRIEVACES AD OTHER COTACTS... 4 ETWORK COTACTS PROCESSIG... 4 Complaints and Inquiries... 4 Involuntary Discharges Patient Placement after Discharge Involuntary Discharge Trending (7-) etwork Proactive Activities Decreasing Dialysis Patient Provider Conflict (DPC) CMS GOAL # COLLABORATIO WITH PROVIDERS AD FACILITIES Large, Independent and Small Dialysis Organizations State Survey Agency... 5 Missouri Kidney Program (MOKP)... 5 Kansas Kidney Coalition (KKC)... 5 Heartland Chronic Kidney Disease (CKD) Coalition... 5 ational Kidney Foundation (KF)... 5 Other Collaborative Activities... 5 Pediatric Dialysis Units... 5 Peritoneal Dialysis Units and Dialysis Centers in Long Term Care Facilities... 5 Prison Based and Veterans Administration and Acute Dialysis Centers PROVISIO OF EDUCATIOAL MATERIALS TO THE REAL COMMUITY Annual Educational Meetings/Conference Heartland Headlines ewsletters and Electronic ewsletters Draft submitted: May 5,

4 Heartland Kidney etwork Annual Report 3 The etwork Website Educational Resources Regional and ational Patterns of Care CMS GOAL # IMPROVE THE DATA COLLECTIO, RELIABILITY, AD TIMELIESS etwork Annual Report Forms Compliance Improvement Process Fistula First Breakthrough Initiative (FFBI) CROWWeb USE OF DATA TO MEASURE PROCESSES OF CARE AD OUTCOMES Annual Facility Scorecard SUPPORT THE ESRD ETWORK PROGRAM SACTIO RECOMMEDATIOS RECOMMEDATIOS FOR ADDITIOAL FACILITIES DATA TABLES ETWORK ICIDET DATA ETWORK PREVALECE DATA SPECIAL OTE O DATA TABULATIO Appendices through 8 Draft submitted: May 5,

5 Heartland Kidney etwork Annual Report 4 A Letter from the Board President On behalf of the Medical Review Board (MRB), the Board of Directors (BOD) and the staff at Heartland Kidney etwork, the Annual Report is provided to the Contracting Officer Representative (COR) for review and approval. The deliverable encompasses the initiatives and the activities the etwork pursued during the calendar year of Centers for Medicare and Medicaid (CMS) contract #HHSM-5--WC. This document provides an overview of the work completed by the etwork during. Whether it is facility level quality improvement, network-wide quality improvement, educational opportunities, patient complaint or grievance concerns or quality of care issues, the beneficiary remains at the center of all etwork activities. Utilizing CMS recommendations and input from the renal community we serve, the MRB and the BOD of the etwork have reaffirmed their commitment to the success of the etwork s quality oversight of dialysis and transplant centers in the states of Iowa, Kansas, Missouri, and ebraska. The Boards continue to take an active role in the planning and evaluation stages of quality improvement projects, development of facility specific goals, development of educational materials, roles and responsibilities of the dialysis facilities to the etwork, evaluating and mediation of complaints and grievances from our beneficiaries. In addition to these duties the etwork continues to offer technical support and regulatory recommendations to facilities in order to maintain the best quality healthcare possible for our population. Respectfully submitted by: Wendy Funk-Schrag, LMSW, ACSW Board President (-3) Draft submitted: May 5,

6 Heartland Kidney etwork Annual Report 5 Introduction etwork Description Heartland Kidney etwork encompasses the four states of Iowa, Kansas, Missouri, and ebraska covering approximately 85,64 square miles with a population base of 3.7 million persons. The dialysis and transplant facilities are situated in densely populated urban areas, suburbia, and small rural towns. There are no dialysis facilities in 65 of the 4 counties in the four-state region (64.3%). An additional one hundred and eleven () counties only contain one facility. The highest concentrations of facilities are in the St. Louis and Kansas City areas, corresponding to the density of the population. Ownership of the facilities in Heartland Kidney etwork includes large dialysis corporations, hospitals, independent physician/physician groups, small independent organizations, and the Veterans Administration. Sixty-seven percent of the facilities are owned/managed by large dialysis corporations (LDOs). This is an increase of six percent over the previous year. Twenty-eight percent of the facilities remain independently owned. As of December 3,, the patient census per facility within Heartland Kidney etwork (including both in-center and home dialysis patients) was reported from patient to patients. Eighty-nine (3.7%) reported thirty or less patients, while thirty-one facilities (.4%) reported one hundred or more patients. There are 7 transplant centers in Heartland Kidney etwork, in which 87 kidney transplants were performed during (a 7. increase over ): 57 in Iowa, 48 in Kansas, 43 in Missouri, and 36 in ebraska. Population Demographics The population of the etwork area reported in the 99 census was.7 million with an increase to.9 million reported in the census and 3.7 million reported in the census. Estimated and actual counts for the four-state area are as follows: July, :,9, July, : 3,74,74 July, (est): 3,786,876 Draft submitted: May 5,

7 Heartland Kidney etwork Annual Report 6 Population Tables Table A Demographic Characteristics by State Dec. Iowa Kansas Missouri ebraska Totals White,78,3,39,93 4,958,83,57,48,73,546 Black 88,344 68, ,76 8,85,33,579 American Indian and Alaska ative persons,85 8,53 9,945 8,63 88,95 Asian 5,788 68,475 95,83 3,874 48,96 ative Hawaiian and Other Pacific Islander 3,46,853 5,989,86 3,75 Two or More 54,834 85,594 5,767 4,8 36,375 Male,57,946,45,47,934,574 95,865 6,763,53 Female,538,49,437,97 3,54,353 9,476 6,95,9 State Total 3,46,355,853,8 5,988,97,86,34 3,74,876 U.S. Census Bureau, Population Division, State Population. Release Date: December The sum of the six race groups may add up to more than the total population because they are estimates calculated on overall population growth, and rely on previous tables where individuals may have reported more than one race. Table B 8 9 Iowa,983,36 3,8,33 3,46,355 Kansas,795,57,87,43,853,8 Missouri 5,95,844 5,98,34 5,988,97 ebraska,78,43,794,85,86,34 Totals 3,5,9 3,6,847 3,74,876 Total U.S. Population 38,745,538 U.S. Census Bureau: Census Draft submitted: May 5,

8 Heartland Kidney etwork Annual Report 7 ESRD Population Demographics Incidence Four thousand, three hundred thirteen (4,33) persons initiated chronic renal replacement therapy including transplantation, at a facility located within the Heartland Kidney etwork region during. Adjusted incidence rates per, persons for the four-state region are as follows: Iowa 3.7 Kansas 9. Missouri 34.9 ebraska 5. When analyzed by race, disparities in incidence rates become quite noticeable between white and black. (See Figure ). This information assisted in the focus of additional educational interventions, both as a etwork and in collaboration with other renal partners. The adjusted incidence of American Indian/Alaska ative and ative Hawaiian or other Pacific Islander may be skewed due to the low population of this group since there were only 6 incident patients in the four states. The adjusted incidence rate of males is also higher than females in each of the four states as consistent with previous years. The difference in Missouri is 9.35 per, patients while the other three states range from 5.44 to 8.9 per, patients. In the Heartland Kidney etwork, diabetes Figure continues to be the primary cause of renal failure. For 48.3 percent of the patients starting renal replacement therapy in, it was identified as the primary cause of kidney failure. This was an increase of.9 percent over data. Hypertension was the second-leading primary diagnosis, accounting for 5. percent (a.3 percent increase from ) of all new patients. Combined, these two diseases accounted for 73.4 percent (a. increase from ) of the renal failure leading to initiation of dialysis or transplantation during. Please refer to Table # in appendices for detailed demographics. Draft submitted: May 5,

9 Heartland Kidney etwork Annual Report 8 In past years, over half of the newly diagnosed ESRD patients were 65 years of age or older. In this trend has increased to 5.% (an increase of.4% from ). Of the dialysis patients prevalent on December 3,, over 45 percent (46.%) were 65 years of age or older. This is a.3% increase from the previous year. Dialysis Prevalence by Modality At the end of, there were 4,75 patients actively dialyzing at a facility in Heartland Kidney etwork. Of the 4,75 persons,,433 resided in Iowa,,673 in Kansas, 7,5 in Missouri, and,568 in ebraska, with 8 patients living in contiguous states while receiving treatment from a Heartland Kidney etwork facility. The heaviest concentration of dialysis patients continues to be around Missouri s major metropolitan areas: St. Louis and Kansas City. A relatively high percentage of patients being treated at Heartland Kidney etwork dialysis units continue to choose home therapies with an increase in home hemodialysis and CAPD. State percentages range from 3.7 percent (MO) to.4 percent (IA) with a etwork-wide total of 6.4 percent. etwork-wide, Continuous Cyclic Peritoneal Dialysis (CCPD) is the most common with 95 patients, 48. percent (a.% decrease over ) of the home population. Six hundred thirty-six patients or 33. percent of the home population were receiving Continuous Ambulatory Peritoneal Dialysis, a. percentage point decrease from. Three hundred fifty-nine patients were on home hemodialysis (8.7 percent of the home population) which is a. percentage point decrease from. Draft submitted: May 5,

10 Heartland Kidney etwork Annual Report 9 Table C: umber and Percent of Patients by Setting and Modality Iowa Kansas Missouri ebraska umber Percent of All Dialysis umber Percent of All Dialysis umber Percent of All Dialysis umber Home HEMO CAPD CCPD IPD In-Center (HD and PD) Totals Percent of All Dialysis Transplant Transplant centers located in the four-state region performed 88 kidney transplants during. Distribution of the recipients is interesting with a relative high occurrence of transplantation in the pediatric population with patients nineteen years of age or younger are more likely to receive a transplant than patients over the age of 65. (Compare Figures and 5). A disproportionately high number of persons in the categories of Whites, Asian/Pacific Islander, and Other/Multiracial are transplant recipients. Many factors including Draft submitted: May 5,

11 Heartland Kidney etwork Annual Report blood type, antigen typing, concomitant disease, and overall health may account for this inequitable distribution as well as the small population of Asian/Pacific Islander and Other/Multiracial within Heartland Kidney etwork. As of the end of, the etwork-area transplant centers reported,7 patients are awaiting transplantation. Of the 7 transplant centers reporting the number of patients waiting for transplant, 9 show an increase in the number of patients with the increases ranging from 5 patients to 99 patients. Only one state, ebraska, reported a decreased number of patients waiting for a transplant. However, all states reported an increase in the number of transplants performed. (Patients may be listed with more than one transplant center located in the four-state region and the number may represent patients who live and dialyze outside of the area.) Deaths Three thousand ninety patients died during. The age group in which the largest number of persons died was the year old range, which is also disproportionate for this age group's population (see Figure 6). The leading known causes of death were cardiac related (3.7%); other (6.9%) and unknown accounting for 6.9 percent (see Figure 7). Please refer to the Data Tables, for specific information on the ESRD population receiving treatment within Heartland Kidney etwork. etwork Structure CORPORATE DESCRIPTIO End-Stage Renal Disease (ESRD)- etwork Coordinating Council, Inc., is a not-for-profit corporation founded in Missouri on ovember 7, 975. Then as now, the primary business is fulfillment of a federal contract as part of the ESRD Program within Medicare. Heartland Kidney etwork s leaders and the evolution of the ESRD Program have driven the organization s development. Draft submitted: May 5,

12 Heartland Kidney etwork Annual Report History The Medicare End Stage Renal Disease (ESRD) Program, a national health insurance program for people with end stage renal disease, was established in 97 with the passage of Section 99I of Public Law The formation of ESRD etwork Organizations was authorized in 978 by Public Law 95-9 which amended Title XVIII of the Social Security Act by adding Section 88. Thirty-two ESRD etwork areas were initially established. In 986, the Omnibus Budget Reconciliation Act of 986 (P.L ) amended Section 88c of the Social Security Act to establish at least 7 ESRD etwork areas and revised etwork Organizations responsibilities. On July, 988, CMS awarded contracts to 8 geographically designated etworks to administer various aspects of the ESRD program. In (c) of the Act was amended by P.L. -39 to specify confidentiality and the extent of etwork liability. Since 99, CMS has awarded three-year contracts to the etworks. Today, the 8 ESRD etworks under contract to CMS serve as liaisons between the federal government and the providers of ESRD services. The etworks responsibilities include: quality monitoring and improvement of the care that ESRD patients receive, the collection of data to administer the national Medicare ESRD program, and the provision of technical assistance to ESRD patients and providers. ESRD etwork Organizations are responsible for: Encouraging the use of those treatment settings most compatible with the successful rehabilitation of the patient; Encouraging the participation of patients, providers of services, and ESRD facilities in vocational rehabilitation programs; Developing criteria and standards relating to the quality and appropriateness of patient care; Evaluating procedures used by facilities and providers to assess the appropriateness of patient treatment type; Implementing procedures for evaluating and resolving patient grievances; Conducting on-site reviews of facilities and providers, as necessary, utilizing standards of care established by the etwork; Collecting, validating and analyzing data for the preparation of reports and assuring the maintenance of a national ESRD registry; Identifying facilities consistently not meeting etwork goals, assisting facilities in developing appropriate plans for correction, and reporting to the Secretary (CMS) on facilities and providers that are not providing appropriate medical care; Draft submitted: May 5,

13 Heartland Kidney etwork Annual Report Submitting an annual report to include: o etwork s goals, and activities conducted to meet goals o Data on the comparative performance of facilities with respect to patients in self-care settings, transplantation, and vocational rehabilitation programs o Identifying facilities that have consistently failed to cooperate with etwork goals o Recommending additional or alternative ESRD services or facilities in the etwork area o Establishing a etwork Council to include dialysis and transplant facilities in the etwork area and a MRB to include physicians, nurses, social workers and at least one patient The ESRD etwork Program s strategic vision is to ensure the right care for every person every time. Overarching ESRD Program goals include: Improve the quality and safety of health care services provided in dialysis and transplant facilities for patients with ESRD; Improve the quality of life for individuals with ESRD through the end of life; Establish and improve strategic partnerships and renal coalitions at the national and regional level to ensure optimum quality of care along the continuum of CKD/ESRD; Improve the collection, reliability, timeliness, and use of data to measure processes of care, outcomes and support the ESRD program; The etworks support the Health Care Quality Improvement Program (HCQIP) mission of patient-centered, effective, safe, efficient, equitable and timely care by assisting ESRD providers and facilities to assess and improve the care provided to individuals with ESRD etwork Coordinating Council Membership in the Heartland Kidney etwork Council is extended to one representative of every ESRD facility located within the four-state region. Delineated in the bylaws, Council representatives have rights and responsibilities similar to shareholders. The Council determines its committee representatives responsible for implementing the corporation s bylaws and overseeing the company s business. The three standing committees of the Council are as follows: the Board of Directors, the Executive Committee (a committee of the Board of Directors), and the Medical Review Board. Members of the Board of Directors, Medical Review Board, Council representatives, and the etwork staff are a select group of individuals passionate about the care of persons with chronic kidney Draft submitted: May 5,

14 Heartland Kidney etwork Annual Report 3 disease. This mutual interest is served by working together to fulfill not only the products and services required by the CMS contract, but to implement our corporate mission. Mission, Vision & Core Values Guided by the leadership of the Board of Directors, Heartland Kidney etwork s ultimate goal is to ensure and improve the quality of care renal patients receive at facilities within our four-state region. The organization s Mission, Vision and Core Values were reevaluated as part of Board of Directors retreat in the spring of 6. The Mission and Vision statements were reevaluated by etwork staff in July with no modifications. The statements are listed below: Mission Heartland Kidney etwork promotes and facilitates high quality care standards for dialysis and kidney transplant patients in Iowa, Kansas, Missouri and ebraska. Vision Heartland Kidney etwork leads and coordinates quality improvement initiatives through collaborative efforts to positively impact the clinical care for chronic kidney disease (CKD) patients. Core Values Humanitarianism: People-centered organization. (We respect rights, individual beliefs, show compassion, share all resources, and listen.) Fairness: Professionalism: Accountability: Integrity: Being just in all dealings. Represents self and organization through responsible and ethical behavior. Accepting responsibility for the consequences of one s actions or inaction. Consistently maintains high standards of trust. Board of Directors The Board of Directors (BOD) has the full authority of the Council. The BOD leadership consists of the President, President-Elect, Secretary, Treasurer and Immediate Past President. In addition, the Chair of the Medical Review Board is also a member of the Board of Directors. BOD members include nephrologists from each state in the etwork region, a facility administrator, a renal social worker, a renal dietitian, a transplant surgeon, and one patient representative. The BOD meets quarterly to manage and monitor financial, personnel and other administrative matters. During, the Board of Directors was involved in the following activities: Fiscal oversight of the organization; Draft submitted: May 5,

15 Heartland Kidney etwork Annual Report 4 Evaluated the co-employer agreement with Insperity which manages and administers employee benefits and provides human resources support; Planned the educational portion of the Annual Business Meeting and Educational Conference; Performed the first annual Corporate Compliance Audit The Medical Review Board (MRB) is responsible for the coordination of quality improvement activities and other activities as set forth in the CMS contract. The MRB is composed of ESRD professionals and patients including, nephrologists, a registered nurse, a renal social worker, a renal dietitian, a transplant surgeon, a pediatric nephrologist, a facility administrator, a renal technician, and four patient representatives. During, these activities included the following: Development of all projects for the Quality Improvement Work Plan (QIWP) designed to improve the quality of health care delivered to ESRD patients; Patient grievance reviews; Oversight of the Clinical Performance Measures data collection; Review and strategic planning to meet the goals of the Fistula First Breakthrough Initiative. Standing Committees and Responsibilities The etwork utilizes ad hoc committees and subcommittees to direct project specific and business needs of the organization. These small groups review the details of the etwork activities and make recommendations to the appropriate board upon review. Committee and their responsibilities were modified in accordance with the revision of the etworks Bylaws in March of 9. These committees met as-needed basis throughout the year. The individual committee activities and responsibilities are as follows: Executive Committee A Committee of the Board of Directors The role of Executive Committee (EC) is to fulfill the duties delegated to it by the Board and shall have and exercise all the powers of the Board at such times when the Board is not in session. The EC is responsible for detailed oversight of the etwork operations and finances. These duties include review and development of personnel policies, staffing requirements, job descriptions, executive compensation Draft submitted: May 5,

16 Heartland Kidney etwork Annual Report 5 and evaluation, fringe benefits, and oversight of general corporate financial affairs. During, the Executive Committee was involved in the following: Continuous monthly oversight of the accounting procedures; Cash flow management review; Review and revision of Fiscal Policies. Audit/Finance Committee A Committee of the Board of Directors The Finance/Audit Committee is responsible for overseeing () the integrity of the Corporation s financial statements, () the Corporation s compliance and legal regulatory requirements, (3) the independent auditor s qualifications and independence, (4) the performance of the Corporation s independent auditor, and (5) the Corporation s internal audit and internal controls regarding finance and accounting. Governance Committee A Committee of the Board of Directors Established as part of the March 9 Bylaw revision, the Governance Committee assists the Board in perpetuating the effectiveness of the Corporation through () periodic review of the Corporation s Bylaws and developing revisions of the Bylaws for Board consideration; () periodic review of Board policies and procedures and developing such necessary revisions for Board action; (3) evaluating Board performance; (4) identifying the qualities and characteristics required for effective governance; (5) identifying, developing, and training effective Directors and Officers; (6) serving as the Corporation s ominating Committee to nominate candidates for election to the Board, as Officers of the Corporation and to serve as members of the MRB; and (7) overseeing the Corporation's corporate compliance plan and its system of internal controls regarding legal compliance and ethics as established by the Board and the Corporation's staff from time to time. The Governance Committee completed the first annual Corporate Compliance Audit during. The results will be reported to the joint board meeting in February. The Governance Committee also approved the first Corporate Compliance Training which will be presented in early. Patient Advisory Committee A Subcommittee of the Medical Review Board Established in 7, this committee of transplant and dialysis patients provides recommendations for new approaches, updates educational materials, and reviews content for patient resources. The committee began with four members from the Medical Review Board and one Board of Directors Draft submitted: May 5,

17 Heartland Kidney etwork Annual Report 6 patient representative. It has grown to include a total of eighteen members. The membership represents each of the four states, each modality option and patient care partners and family members. Fistula First/FFBI Committee A Subcommittee of the Medical Review Board Formed in the fall of 3, the Fistula First Subcommittee has guided the etwork in designing and evaluating etwork s Fistula First activities. The Fistula First committee works closely with the etwork Quality Improvement (QI) staff to review data, plan interventions, and strategize ways to overcome barriers in order to meet contractual goals. In addition to the etwork QI staff, this ten-member committee consists of four physicians, one surgeon, two registered nurses, one patient representative, one administrator and at least one etwork staff member. Grievance Committee A Subcommittee of the Medical Review Board The Grievance Committee reviews and makes determinations on formal grievances. The MRB Chair- Elect serves as chairman for this committee. The Patient and Community Services Specialist holds investigative calls with the committee as needed to discuss recommendations, corrective action planning, mediation, and referral activities. Six members of the Medical Review Board, including two patient representatives, serve on this committee. Quality Agenda Committee A Subcommittee of the Medical Review Board The Quality Agenda Subcommittee was charged, by the BOD and MRB, with determining the quality improvement needs of the etwork and developing resource-appropriate interventions to address these issues. Goal setting, brainstorming interventions, and assisting with data analysis are ways in which this committee has been beneficial. In addition to the etwork staff, membership includes, at a minimum, a physician, registered nurse, patient, social worker, and registered dietitian. Transplant Evaluation Committee A Subcommittee of the Medical Review Board and Board of Directors Established in 6, this ad-hoc subcommittee of the Board of Directors and the Medical Review Board, reviews transplant data, makes recommendations for educational interventions, and oversees the Mission Referral Quality Improvement Project. ine members, including three patient representatives, serve on this subcommittee. Draft submitted: May 5,

18 Heartland Kidney etwork Annual Report 7 Board of Directors Membership Wendy Funk Schrag, LMSW, ACSW President (-3) Surendra Shenoy, MD, PhD President-Elect (-3) Transplant Surgeon Consultant/SME QI David Goldner, MD Immediate Past President (-) JoAnn Zynda, R, BA, C Treasurer (-3) Thomas Bainbridge, MD * ephrologist Joseph Bast, MD * ephrologist Ardy Boucher Patient Representative Deanna Coffey, MSW, LCSW * Social Worker David R. Gile, MD * ephrologist Laurie Hippensteel, R, BS Administrator/Treasurer-Elect Richard Lund, MD ephrologist MRB Chair Marie Philipneri, MD, MPH * ephrologist Les Spry, MD, FACP, FAS ephrologist Christie P. Thomas, MD * ephrologist Jennifer Strong, MS, RD, CSR,LMT * Dietitian Katrina M. Dinkel, MA Executive Director FMC - ewton ewton, Kansas 674 Washington University St. Louis, Missouri 63- Omaha ephrology PC Omaha, ebraska 684 DaVita Sun Dance Region 4 Lenexa, KS 665 Southeastern Renal Dialysis, LC Mt. Pleasant, Iowa 564 Omaha ephrology PC Omaha, ebraska 684 FMC Des Moines, Iowa 534 University of Missouri Health Care Columbia, MO 65 Wichita ephrology Group Wichita, Kansas 674 VA Med Center Kansas City Dialysis Creighton ephrology Omaha, ebraska 683 St. Louis University St. Louis, Missouri 63 Dialysis Center of Lincoln Lincoln, ebraska 685 Univ. of Iowa Hospitals & Clinics Department of Internal Medicine Iowa City, Iowa 54 Genzyme Renal Medical Affairs Lincoln, E W Tiffany Springs Pkwy Ste 3 Kansas City, Missouri 6453 Draft submitted: May 5,

19 Heartland Kidney etwork Annual Report 8 Medical Review Board Membership Richard Lund, MD, Chair Chair (-3) Scott Solcher, MD, FACP, Chair-Elect ephrologist Grievance Committee Chair David Sommerfeld, MD Immediate Past Chair (-) Michael Ashley * Patient Representative Tonya Bailey, R, BS, MA, LSSGB * Administrator Patrick Brophy, MD Pediatric ephrologist Marius Florescu, MD * ephrologist orma Knowles, MSW, LCSW * Patient Representative Connie L. Kramer, MS, ARP-BC, C * urse Practitioner Brent Miller, MD * ephrologist Stuart Mott * Renal Technician Judy Robbins * Patient Representative Robert Smith, DO ephrologist Sally Tyner, MS, RD, LD * Dietitian Lisa VanHoose, MSW Renal Social Worker Mark Wakefield, MD * Transplant Surgeon Wendy Funk Schrag, LMSW, ACSW BOD President (-3) Katrina M. Dinkel, MA Executive Director Creighton ephrology Omaha, ebraska 683 KDS - Lawrence Lawrence, KS 6646 Springfield ephrology Springfield, Missouri Iowa patient representative DaVita Swope Dialysis Clinic University of Iowa Children s Hospital Iowa City, Iowa 54 University of ebraska Medical Center Missouri patient representative Tri-State Dialysis Dubuque Dubuque, Iowa 5 Barnes Jewish Dialysis Center St. Louis, MO 638 DCI-Columbia Columbia, MO 65 ebraska patient representative Associated Kidney Care Des Moines, Iowa 534 DaVita orthland orth Kansas City, MO 646 DCI-Jefferson City East Jefferson City, Missouri 65 Univ. of Missouri Hospital Transplant Columbia, MO 65 FMC - ewton ewton, Kansas W Tiffany Springs Pkwy, Ste 3 Kansas City, Missouri 6453 Draft submitted: May 5,

20 Heartland Kidney etwork Annual Report 9 Board Subcommittee Membership Standing Committees EXECUTIVE (EC) A Committee of the Board of Directors Wendy Funk Schrag, LSCW, ACSW President Surendra Shenoy, MD, PhD President-Elect Laurie Hippensteel, R, BS, Treasurer Richard Lund, MD, MRB Chair Katrina M. Dinkel, MA, Executive Director GOVERACE A Committee of the Board of Directors Wendy Funk Schrag, LSCW, ACSW, President Katrina M. Dinkel, MA, Executive Director Chuck Schwegler, R (Kansas) Joanne Cooke, MS, RD, LD, CSR (Missouri) Karma J. Dorn, R, Dir. of Operations (ebraska) Tawnya Salsbery, MS, R, C (Iowa) President, ED, non-director rep from EACH of the states in the etwork FIACE & AUDIT A Committee of the Board of Directors Laurie Hippensteel, R, BS, Treasuruer Joseph Bast, MD, non-officer* Ardy Boucher, non-officer* Wendy Funk Schrag, LSCW, ACSW, President David A. Backus, CPA non-voting or abstention Katrina M. Dinkel, MA, Executive Director Treasurer plus at least two () non-officer Directors* who possess particular expertise in financial and accounting matters as chosen by the President. The President may also appoint one () or more non-director members of the Committee who possess special expertise in financial matters to serve as independent members of the Committee with vote. The President and Executive Director shall serve on the Audit/Finance Committee without vote. GRIEVACE A Subcommittee of the Medical Review Board Richard Lund, MD, MRB Chair orma Knowles, Patient Rep Tonya Bailey, R, BS, MA, LSSGB (Administrator) Lisa VanHoose, MSW Anne Karanja, MPH DeeDee Velasquez-Peralta, LMSW Katrina M. Dinkel, MA TRASPLAT EVALUATIO An Ad-hoc Subcommittee of the Board of Directors and the Medical Review Board Ardy Boucher, BOD Patient Rep Wendy Funk Schrag, LSCW, ACSW, President Richard Lund, MD, MRB Chair Surendra Shenoy, MD, PhD, President-Elect Judy Robbins, Patient Rep Kay Brown, BS Cathy Long, BA, RHIT, CPHQ QUALITY AGEDA An Ad-hoc Subcommittee of the Medical Review Board Richard Lund, MD, MRB Chair Sally Tyner, MS, RD, LD, Dietitian orma Knowles, Patient Rep Connie L. Kramer, MS, ARP-BC, C Kay Brown, BS Cathy Long, BA, RHIT, CPHQ Draft submitted: May 5,

21 Heartland Kidney etwork Annual Report PATIET ADVISORY (PAC) A Subcommittee of the Medical Review Board FISTULA FIRST/FFBI COMMITTEE An Ad-Hoc Subcommittee of the Medical Review Board Ardy Boucher, Chair, Patient Rep (IA) orma Knowles, Vice Chair, Patient Rep (MO) Mike Ashley, Patient Rep (IA) Stuart Boley, Beneficiary Family Member (IA) * azaree Doleman, Patient Rep (KS) Sue Donaldson, Patient Rep (E) Korrinee (Korri) Hoeger, Patient Rep (IA) Russ & Mitzi Hoeger, Benef. Family Member (IA)* Kevin Lix, Patient Rep (KS) Stuart Mott, LP, Renal Professional (MO)* Carol Musick, Beneficiary Family Member (KS)* Thomas Musick, Patient Rep (KS) Cliff Robbins, Beneficiary Family Member (E)* Judy Robbins, Patient Rep (E) Gloria Smith, Patient Rep (MO) Richard Lund, MD, MRB Chair (Champion) Scott Solcher, MD, MRB Chair-Elect Surendra Shenoy, MD, PhD, President-Elect Kay Brown, BS Cathy Long, BA, RHIT, CPHQ *The PAC may appoint beneficiary family members of the existing PAC committee members and renal professionals who are already involved with the etwork Medical Review Board (MRB) and or the Board of Directors (BOD) Committees. Draft submitted: May 5,

22 Heartland Kidney etwork Annual Report Heartland Kidney etwork Staff December 3, (with responsibilities) Katrina M. Dinkel, MA Executive Director Kristen Oehlert Event and Communication Coordinator Debbe Ulm Senior Project Manager Kay Brown, BS Quality Improvement Director Cathy Long, BA, RHIT, CPHQ Quality Improvement Coordinator Bea Wachira, R, BS Quality Improvement urse Specialist Anne Karanja, MPH Community Development Manager DeeDee Velasquez-Peralta, LMSW Patient and Community Services Specialist Jeff Arnall, MCSE, PMP Information Systems Director Financial Management CMS Liaison Renal Community Liaison Daily Operations Personnel Management Meeting & Event Planning Board Liaison Correspondence and Office Communications Administrative Duties Board Liaison Correspondence and Office Communications Administrative Duties Financial Liaison with Accountant Fistula First Breakthrough Initiative Quality Improvement Activities Facility Regulation Information USRDS Studies Coordination Facility and Staff Education Clinical Performance Measures (CPM) Data Collection Corporate Compliance Officer (Appointed August ) Quality Improvement Project Management Fistula First Breakthrough Initiative Quality Improvement Activities Facility Regulation Information USRDS Studies Coordination Facility and Staff Education Clinical Performance Measures (CPM) Data Collection Fistula First Breakthrough Initiative Quality Improvement Activities Facility Regulation Information Facility and Staff Education Medical Chart Review Cannulation Kit Management Patient Grievances and Facility Concerns Patient and Staff ewsletters Community Outreach Facility and Patient Education Coalition Liaison State Survey Liaison Patient Grievances and Facility Concerns Technical Assistance Emergency Preparedness Patient & Facility Education Conditions for Coverage/ State Survey Readiness Resource Development Coalition Liaison Clinical Technical Assistance Computer Administration SIMS Database Management Computer System & Data Integrity Management CMS Data Contact Data Request Processing Web Master Draft submitted: May 5,

23 Heartland Kidney etwork Annual Report Serena Timko Information Systems Assistant Forms Compliance Reporting Facility Education on Forms Vision Software Contact Annual Facility Survey Facility Education on Rosters Quarterly Patient Rosters Facility Services Data Maintenance Processing of 78 and 746 Forms Monthly Patient Activity Rosters Heartland Kidney etwork Staff Members and Position Descriptions During, Heartland Kidney etwork employed ten full-time employees (FTE s). The stability of our workforce is instrumental to maintaining efficiency and effectiveness to meet the etwork contractual responsibilities. The average length of employment with the organization is approximately seven years. To ensure continued success of employees and the organization, all staff members are responsible for pursuing continuing education opportunities every year. In 4, the etwork entered into an agreement with a Professional Employer Organization (PEO), Insperity. The PEO takes responsibility for human resource administration and background checks as well as providing payroll services. As part of the agreement, the etwork employees are considered coemployees of both Heartland Kidney etwork and Insperity. Administration Executive Director Katrina M. Dinkel, MA The Executive Director (ED) reports to and serves as the primary staff support to the Board of Directors. The ED is responsible for the overall management and coordination of ongoing organizational activities to fulfill the CMS contract requirements and deliverables. In addition to managing all day-today business of the etwork, the ED is charged with financial and personnel activities, while overseeing all departments of the organization. Additionally, the Executive Director serves as the liaison to both the Centers for Medicare & Medicaid Services (CMS) and the renal community while ensuring effective working relationships with Department of Health & Human Services (DHHS), the State Survey Agencies of Iowa, Missouri, Kansas, and ebraska, facility staff members, and other renal-related organizations involved in the provision, monitoring and improvement of ESRD patient care. Event & Communication Coordinator Kristen Oehlert The Event and Communication Coordinator reports to the Executive Director and provides ongoing administrative support to the etwork. Areas of responsibility for this position include effective Board communication, coordinating special projects, educational events and training arrangements and some Draft submitted: May 5,

24 Heartland Kidney etwork Annual Report 3 website support. The Coordinator works with the Executive Director and planning committee to manage the Annual Business Meeting and Educational Conference by working with vendors and corresponding with speakers while meeting budget constraints. Senior Project Manager Debbie Ulm The Senior Project Manager reports to the Executive Director and provides ongoing administrative support to the etwork. Areas of responsibility for this position include coordinating special projects and events, Board of Directors and Medical Review Board liaison, and general office management. The Senior Project Manager works with the Executive Director, Event & Communication Coordinator, and planning committee to assist with the Annual Business Meeting and Educational Conference. Quality Improvement Quality Improvement Director Kay Brown, BS The Quality Improvement Director (QID) reports to the Executive Director. The QID is a resource to and the direct supervisor of the Quality Improvement Coordinator. The QID is responsible for coordinating Quality Improvement activities for the four-state area. This includes, but is not limited to, being a resource to facilities in dealing with clinical questions and Continuing Quality Improvement (CQI), employee management issues, providing technical assistance, difficult management situations, distribution of educational materials, and unit policy enforcement. Additionally, the QID obtains intervention materials, consults with the statistician, reports to the Medical Review Board (MRB), and coordinates the Clinical Performance Measures (CPM) project. The QID coordinates the Internal Quality Plan of the etwork. The QID serves as the Corporate Compliance Officer to ensure corporate compliance of the etwork staff, boards and patient advisory committees. The QID also functions as the secondary Security Point of Contact (SPOC) and works with the SPOC to ensure security measures. In the absence of the QID, the Quality Improvement Coordinator covers the majority of these responsibilities. Quality Improvement Coordinator Cathy Long, BA, RHIT, CPHQ The Quality Improvement Coordinator (QIC) reports directly to the Quality Improvement Director. In the absence of the Quality Improvement Director, the QIC is responsible for the completion of deliverables and maintaining an efficient QI department. The QIC is involved in all aspects of the Draft submitted: May 5,

25 Heartland Kidney etwork Annual Report 4 etwork quality initiatives: from project development to writing the final report. The QIC completes the data entry and analysis tasks related to the quality improvement initiatives. Quality Improvement urse Specialist Beatrice Wachira, R, BS The Quality Improvement urse Specialist reports directly to the Quality Improvement Director. The QI urse is involved in all aspects of the etwork quality initiatives: from project development to writing the final report. In the event of the QIC s absence, the QI urse covers data entry for QI initiatives. He/she also works closely with the CIR department and MRB to develop educational materials of a clinical nature. This position is responsible for medical chart review and evaluating state survey reports for QI involvement in corrective actions. Community Information & Resources unity Information and Resources Community Development Manager Anne Karanja, MPH The Community Development Manager (CDM) reports to the Executive Director. The CDM is responsible for coordinating Patient Services activities for the four-state area. The CDM is responsible for acting as a resource to facilities, including but not limited to, assistance in dealing with clinical questions, technical assistance, and difficult situations. The CDM coordinates patient education/support activities including the development and distribution of educational materials and educational training. The CDM also performs the functions of the Community Outreach Coordinator. The CDM serves as liaison between the State Survey Agencies and other patient-centered organizations/agencies. The Patient Services and Quality Improvement departments work together on various projects and to provide technical assistance as needed. In the absence of the CDM, the Patient and Community Services Specialist covers these responsibilities. Patient and Community Services Specialist (Position Created October ) DeeDee Velasquez-Peralta, LMSW The Patient and Community Services Specialist (PCSS) reports to the Executive Director with supervisory oversight from the Community Development Manager. The primary responsibility of the PCSS is to assist patients and facilities in resolving complaints or grievances. The PCSS is responsible for acting as a resource to facilities, including but not limited to, assistance in dealing with clinical questions, technical assistance, and difficult situations. The PCSS provides ongoing assessment and revises emergency preparedness plans for the etwork office. It is a responsibility of this position to assess the etwork facility emergency preparedness and state survey readiness. Draft submitted: May 5,

26 Heartland Kidney etwork Annual Report 5 Information Management Information Systems Director Jeff Arnall, MCSE, PMP The Information Systems Director (ISD) reports to the Executive Director. The ISD continually assesses and revises data management system output to ensure efficiency, accuracy, Computer System Integrity Management, and adherence to CMS and etwork requirements. The ISD ensures compliance of all data requirements including SIMS Database Management, facility accuracy & compliance profiles, facility directory information, data storage, security/confidentiality, and CMS-78, CMS-746, and CMS-744 submissions. It is a responsibility of this position to oversee implementation of SIMS, VISIO, CROWWeb, Qualityet Exchange and related hardware/software updates, facility training and security measures. The Information Systems Director serves as a resource to the Medical Review Board and Quality Improvement staff as needed/requested. The ISD coordinates the processing of all data requests and is the primary data interface with CMS officials and contractors, Social Security offices and HMOs regarding ESRD Medicare entitlement situations. Information Systems Assistant Serena Timko The Information Systems Assistant (ISA) reports to the Information Systems Director. Responsibilities include assisting with report writing and data cleanup analysis, web site updates, performing ongoing data entry of the CMS-78, CMS-746 and CMS-744, Annual Facility forms, following-up on all new patients, transfers, deaths, transplants, facility personnel updates and other patient related events including those submitted through VISIO. The Information Systems Assistant uses data utilities to prepare periodic accuracy and compliance profiles, missing/incomplete forms summaries and other facility feedback reports while preparing notices to facilities with delinquent CMS and etwork data forms. The ISA analyzes forms compliance and provides facility education regarding the forms as needed. Additionally, the Information System Assistant is charged with maintaining wellorganized hard copy files of forms and providing monthly etwork Patient Status forms. The Information Systems Assistant researches and responds to facility inquiries regarding CMS and etwork forms/data reporting requirements. The ISA also acts as a resource to the renal community in educating on the use of various data collection tools and software. CMS ational Goals and etwork Activities The following table provides a synopsis of the CMS ational goals as well as examples of how the etwork achieved each of the goals in. Draft submitted: May 5,

27 Heartland Kidney etwork Annual Report 6 CMS ESRD Program Goals Examples of how Heartland Kidney etwork performance/activities met the goal #. Improve the quality and safety of dialysis related services provided for individuals with ESRD. #. Improve the independence, quality of life, and rehabilitation (to the extent possible) of individuals with ESRD through transplantation, use of self-care modalities (e.g., peritoneal dialysis, home hemodialysis), in-center selfcare, as medically appropriate, through the end of life. #3. Improve patient perception of care and experience of care, and resolve patient s complaints and grievances. #4. Improve collaboration with providers to ensure achievement of the goals through the most efficient and effective means possible, with recognition of the differences among providers (e.g., independent, hospital-based, member of a group, affiliate of an organization, etc.) and the associated possibilities. Quality Measures o Fistula First Breakthrough Initiative (FFBI) o ephrologist and Annual Facility Scorecards o Lab Data Collection o etwork Specific Goals o Quality Improvement Projects Patient Safety and Beneficiary Protection o 5-Diamond Patient Safety Program o etwork Emergency Preparedness o Averting discharges Independence o Patient Advisory Committee (PAC) Quality of Life Vocational Rehabilitation Transplant Immunizations Patient Perception of Care o Patient Advisory Committee (PAC) o etwork Patient Representatives (PR) Patient Educational Resources and Meetings o Patient ewsletter-heartland Headlines o ew Patient Questions for Providers Complaints, Grievances and other Contacts o etwork contacts processing o Complaints and Inquires o etwork Proactive Activities o Decreasing Dialysis Patient Provider Conflict (DPC) Collaboration with Providers and Facilities o Large, Independent and Small Dialysis Organizations o State Survey Agency o Missouri Kidney Program o Kansas Kidney Coalition o Heartland Chronic Kidney Disease (CKD) Coalition o ational Kidney Foundation (KF) o Pediatric Dialysis Units Draft submitted: May 5,

28 Heartland Kidney etwork Annual Report 7 #5. Improve the collection, reliability, timeliness, and use of data to measure processes of care and outcomes; maintain Patient Registry; and to support the ESRD etwork Program. o Peritoneal Dialysis Units and Dialysis Centers in Long Term Care Facilities o Prison Based and Veterans Administration and Acute Dialysis Centers Provision of Education Materials to the Renal Community o Annual Educational Meetings/Conference o Heartland Headlines ewsletters and Electronic ewsletters o The etwork Website o Educational Resources o Regional and ational Patterns of Care Improve the Data Collection, Reliability, and Timeliness o etwork Annual Report o Forms Compliance Improvement Process o Fistula First Breakthrough Initiative (FFBI) o Crown Web Use of Data to Measure Processes of Care and Outcomes o Annual Facility Scorecard o o ephrologists Scorecard Use of elab data in determining QI interventions CMS Goal # The etwork achieved CMS Goal # of improving the quality and safety of dialysis services provided for individuals with ESRD by designing and implementing quality improvement projects which produced rapid and sustained outcomes. The use of facility elab data and vascular access data has given the etwork the ability to identify both high and low performing dialysis centers and to determine where to focus interventions. Rewarding care-givers who provide exemplary care during the Annual Meeting is another means of recognizing and showcasing best performance examples. In addition, the etwork has worked to accomplish this goal through promoting preventive care and safe transitions from one provider to another. Provided below are specific examples of etwork activities which resulted in our achievement of this CMS goal. Draft submitted: May 5,

29 Heartland Kidney etwork Annual Report 8 QUALITY MEASURES Fistula First Breakthrough Initiative (FFBI) Permanent vascular access continues to be a major emphasis in etwork quality improvement and educational activities/projects. In July, a four prong quality improvement project was initiated. The four prongs include: 5/5 focusing on facilities with greater than 5 patients with an AVF percentage below 5%; Facility Specific goals for each facility in the etwork; ephrology scorecards for each nephrologist with at least one incident patient; Cannulation training kit. The project continued through June 3,, include: In July, the etwork initiated another multi-pronged quality improvement project. The prongs All Stars in the Heartland is a project in the form of a baseball game pitting the LDOs against the Independents with AVF, AVG and Catheter rates as the box score; Facility Specific goals for each facility in the etwork; ephrology scorecards for each nephrologist with at least one incident patient; Cannulation training kit. Cannulation Training Kit The etwork provides two kits for cannulation training to be checked out by facilities with limited funds for travel to training. The kit provides tools for an in-service at the facility with cannulation arms to practice on. These kits are checked out for up to 4 days (longer times are available if the facility demonstrates a need for greater time). All materials must be returned to the etwork or the facility would be billed for the entire kit. Annual Facility Scorecards In ovember, both the Unit Administrator and the Medical Director of each facility received the Annual Facility Scorecard which included 6 comparative graphs and tables. Seven of the indicators were based on e-lab reports. These reports were also accompanied by a facility specific letter addressing accomplishments and areas for improvement as well as a letter from the Medical Review Board. In addition to the Annual Facility Scorecard the etwork provided each facility with a trending report on parameters not trended on the Dialysis Facility Report. Draft submitted: May 5,

30 Heartland Kidney etwork Annual Report 9 Lab Data Collection During first quarter Heartland Kidney etwork participated in the Lab Data Collection project which included both hemodialysis and peritoneal dialysis data from October December. The following facility-specific reports were forwarded to the Facility Administrator in April : Facility specific report including comparisons to state and Heartland Kidney etwork data; Comparative graph of the report; Facility HD Percentile compared to etwork HD Percentile; Means and Medians Report; Patient Characteristics with comparisons to state and Heartland Kidney etwork. If peritoneal dialysis information was submitted, separate reports were also distributed. Heartland Kidney etwork utilizes the data from the lab data collection in the compilation of the Annual Facility Scorecard and in the selection of facilities for quality improvement projects. etwork-specific Goals Annually the etwork stimulates improvement through strategizes with the quality improvement projects. Medical Review Board and the Board of Directors work with the Quality Improvement Department to outline the clinical outcome and other etwork-specific goals for the CMS contract year. Once the goals are finalized, each facility, as well as the state survey agencies, is provided with a copy of the goals via the etwork Facility Scorecard Representative. The representatives sign a document attesting that the goals have been received and that the facility will work toward meeting those goals for all of the patients and return the signed form to the etwork. The goals that were chosen for matched those clinical goals that were stated in the ESRD Conditions for Coverage and the Measures Assessment Tool (MAT) from the Centers for Medicare & Medicaid Services except in the case of Phosphorus. The etwork Medical Review Board chose the K/DIGO recommended range over the MAT and KDOQI range. The etwork posts the etwork-specific goals on the website for easy access, download, and reference. Draft submitted: May 5,

31 Heartland Kidney etwork Annual Report 3 The Centers for Medicare & Medicaid Services (CMS) Federal Register, HHS 45. to 45.3, discusses the ESRD etwork responsibilities regarding the formulation of etwork-specific goals and the dialysis facility s responsibility toward meeting them. As directed by the Secretary, the Heartland Kidney etwork s Medical Review Board and Board of Directors have set performance goals that every dialysis facility is expected to achieve. The State Survey Agencies utilize etwork goals and initiatives as a guideline during their evaluation process. QUALITY IMPROVEMET Clinical Performance Indicator Value Vascular Access Fistula Graft Central Venous Catheter ational goal of >66.% in all HD patients and 5.% of incident patients. The anticipated CMS etwork goal by March 3, is 59.5 % in all HD patients and 5% of incident patients. All facilities will be given a facility specific AVF goal based on the CMS etwork calculation. Acceptable, if fistula not possible. Fistula not possible in approximately % of total patient population Avoid, unless bridge to fistula/graft or to PD, if patient is awaiting transplant, or in small adult or pediatric patients. Infection rates are very high with CVC. HD Adequacy Adult HD <5 hours 3x/week Adult HD x/week, RKF < ml/min HD 4-6x/week Kt/V.; Min. 3 hours/tx if residual kidney function <ml/min Inadequate treatment frequency Min. Kt/V./week PD Adequacy Adult PD patient < ml urine output/day Pediatric PD patients, low urine urea Min. delivered Kt/V urea.7/week Min. delivered Kt/V urea.8/week clearance utrition Serum Albumin Preferred: > 4. g/dl bromcresol green (BCG) method Mineral Metabolism Anemia Calcium (corrected) *Phosphorus Intact PTH every 3 months Adult & pediatric Hgb on ESAs Adult & pediatric Hgb off ESAs Adult & pediatric: transferrin saturation Adult & pediatric: serum ferritin Immunization All: >8.4 mg/dl & <. mg/dl *All: mg/dl Adult: 5-3 pg/ml ( pmol/l) Pediatric -3 pg/ml Hgb: -. g/dl Hgb: >. g/dl >% (HD, PD), or CHr >9 pg/cell HD: > ng/ml; PD: > ng/ml ESRD patients will be offered immunization against Influenza, Pneumonia, and Hepatitis B Preventive Care Source MAT version.8 *If goals are not specifically mentioned, please refer to K/DOQI. Unless otherwise stated, the goal is %. *K/DIGO guideline Quality Assessment and Performance Improvement (QAPI): The dialysis facility will measure, analyze, and track quality indicators, per the Conditions for Coverage. All patients will be provided with education on modality options** annually. Draft submitted: May 5,

32 Heartland Kidney etwork Annual Report 3 **Modality options include PD (CAPD and CCPD), HD (In-center and Home), and transplant options (cadaveric donor, Living related donor, Living unrelated donor, and paired-matching) COMMUITY IFORMATIO & RESOURCES Disaster and Emergency Preparedness: All facilities will have plans in place (including back-up plans) and share them with the physicians, staff members and patients. Quarterly drills are encouraged. Facilities must notify the etwork in the event of closure. Facilities are required to contact their local emergency management offices at least annually. Qualified and Trained Staff: The facility staff must meet personnel qualification and demonstrated competencies needed to perform the specific duties of their positions. Educational Information: Resources provided by the etwork will be made available to all patients and staff members. Conflict Resolution: The dialysis facility will follow the Conditions for Coverage related to conflict resolution, internal grievance process, patients rights and responsibilities, patient transfer and involuntary discharge. Facilities must notify the etwork and State Agency prior to all Involuntary Discharges. etwork, Patient Rights & Responsibilities & Grievance Posters: Every dialysis facility will display the poster(s) in a prominent location within all of the patients view. ADMIISTRATIO etwork Council: etwork Facility Representatives (Council Members) will annually provide input to the etwork; which evaluates current initiatives, identifies the needs of the facility and community, and includes suggestions for future initiatives. etwork Facility Representatives will submit a signed copy of the etwork Facility Representative Roles & Responsibilities and participate in the Annual Board Election and etwork bylaw revisions, as necessary. The facility will notify the etwork when their representative changes. Quarterly Facility Report: Each facility representative is required to submit a Quarterly Facility Report to the etwork. Facility Goals: etwork goals will be revised annually and distributed to every facility for acknowledgment. The designated etwork Facility Representative must sign and return (fax or ) the document to the etwork. *The etwork reserves the right to update or revise goals based on CMS contractual and regulatory requirements. A current of copy of the etwork goals is available on the etworks website. IFORMATIO MAAGEMET Compliance: Forms: All facilities will be 9% accurate and timely with their submission of the 78 (Eligibility) and 746 (Death) forms. PAR (Patient Activity Reports): All facilities will submit five out of six monthly PARs for each sixmonth cycle ending in January and July. CROWWeb: Electronic submission of 78 (Eligibility) and 746 (Death) forms and clinical data with a 9% timeliness goal. Perform monthly online validation of current census with any corrections with a 9% monthly timeliness goal. Maintain accurate list of staff contact information in CROWWeb. QIPS: All facilities maintain an adequate number of CROWWeb QIPS user accounts with at least one person per facility. Draft submitted: May 5,

33 Heartland Kidney etwork Annual Report 3 Quality Improvement Projects Active During The following Quality Improvement Projects were initiated and/or completed during : Contract Task Area Project Title Project Description Status Task.a Increasing AVF Prevalence 5/5 Task.a Task.b Task.b Task.c Task.c Vascular Access-All Stars in the Heartland Increasing Albumin in In- Center Adult Hemodialysis Patients Increasing Patients within the Phosphorus Range of mg/dl Hemodialysis Adequacy: Missed or Shortened Treatments Eliminating Healthcare Associated Infections in the Dialysis Facility 5/5 focused on facilities with greater than 5 patients and less than 5% AVF in prevalent patients. All facilities within the etwork were divided between two teams. The teams were given the same interventions and a box score of the teams was published monthly. This spurred competition between the LDOs and the Independent facilities The project took advantage of the 5-diamond program. The etwork used the Health Literacy module of the program to aid the facility in targeting educational materials to the health literacy level of the patient. The project again took advantage of the 5-diamond program. The etwork stressed the use of the Health Literacy module of the program to aid the facility in targeting educational materials to the health literacy level of the patient. Project focus was on tracking missed and shortened treatments and focused education of the patients who miss or shorten their treatments. The project included use of 5-Diamond module Missed Treatments. The project focus was hand hygiene and catheter care audits. Using the CDC methodology facilities completed audits. Facilities were also encouraged to use the 5-diamond module Hand Hygiene. When the new quality incentive program for PY 3 and 4 was finalized, the etwork has moved into aiding the facilities in the HS enrollment process. Completed May. AVF goal met and exceeded as of March 3, data. Final report approved by COR July. Project has already exceeded goal and is nearly at stretch goal on December 3,. Completed May. Goal was met. Final report approved by COR July. The project is on target to meet goal by completion date of May. Completed May. Goal was met. Final report approved by COR July. The project is on target to meet goal by completion date of May. Draft submitted: May 5,

34 Heartland Kidney etwork Annual Report 33 Task.d Catheter Reduction QAIP The etwork worked with an LDO that did not have a formal catheter reduction program to develop one. Interventions included an onsite training session on QAPI, use of data, how to build a project plan and root cause analysis Task.d Anemia Management QAIP The etwork worked with four facilities within the greater Kansas City metropolitan area. The facilities participated in a training session held at the etwork office. The session included: Overview of principles of Quality Improvement, Requirements of conditions for coverage, How to determine facility specific barriers, and How to implement a QAIP to address the barriers. AmGen also presented case studies on Anemia management and protocols. Task.d Continuum of Care QAIP The etwork worked with four facilities within the Kansas City metropolitan area to develop and implement a continuum of care checklist to aid in the smooth transition of new patients. Task.d Advanced Care Planning The etwork worked with six facilities who had expressed a need ( and eeds Assessment) for help in Advanced Care Planning to develop and implement a process for educating patients on Advanced Care Planning Completed May. Goal was met. Final report was approved by COR July Completed May. Goal was met. Final report was approved by COR July The project is on target to meet the goal by completion date of May. The project is on target to meet the goal by completion date of May. PATIET SAFETY AD BEEFICIARY PROTECTIO The Patient Advisory Committee (PAC) of the etwork regularly focuses on patient safety issues as well as patient health information protection. The PAC has been supportive of the 5 diamond patient safety program. The etwork protects sensitive information that is collected, produced, stored and disseminated in the course of our operations. 5 -Diamond Patient Safety Program The Mid-Atlantic Renal Coalition (etwork 5), in collaboration with the ESRD etwork of ew England (etwork ) developed the 5-Diamond Patient Safety Program to assist dialysis facilities with the improvement of both staff and patient awareness of specific patient safety areas. During calendar year, the Quality Improvement Department used multiple modules of the 5-Diamond Patient Safety Program as resources for education in Quality Improvement Projects. Feedback on use of the Draft submitted: May 5,

35 Heartland Kidney etwork Annual Report 34 program within the QI Work Plan was very positive with 83% of those using the modules recommending use in other facilities. The goals of this project are: To build a patient safety culture in every dialysis unit To promote patient safety values To create an awareness of patient safety issues To help dialysis units learn more about specific areas of patient safety Overview: The 5-Diamond Patient Safety Program consists of educational modules, which include the tools and resources necessary for implementation of each patient safety concept. Facilities may complete any of the modules, with only one module, Patient Safety Principles, being mandatory. The module options are as follows: Patient Safety Principles Communication Constant Site Cannulation Decreasing Dialysis Patient-Provider Conflict Emergency Preparedness Hand Hygiene Health Literacy Influenza Vaccination Medication Reconciliation Missed Treatments Patient Self-Managed Care Sharps Safety Slips, Trips, & Falls Stenosis Surveillance Transplantation Thirty-nine facilities have completed at least one diamond and will be recognized during the Annual Meeting. The number of facilities and the number of diamonds achieved are listed in the following table. Draft submitted: May 5,

36 Heartland Kidney etwork Annual Report 35 5-Diamond Program Awards umber of Diamonds (Modules) umber of Facilities 5 or more etwork Emergency Preparedness During the Heartland Kidney etwork was actively involved in ways to address emergency and disasters as related to the renal community: Maintained communication and updates with the lead (etwork 7) Kidney Coalition for Emergency Response (KCER). Heartland Kidney etwork is the contracted backup etwork for KCER and for etwork 7. etwork participation in emergency drills. Webinars and Teleconferences regarding emergency preparedness at the dialysis facility. Convened a subcommittee (ESRD Emergency Subcommittee) to gather information to assist in the Missouri Federal Medical Station planning efforts. ShakeOut Drill ational Earthquake drill Response to Joplin, MO tornado-three dialysis facilities serving patients were impacted by the May, tornado that devastated Joplin, MO. One dialysis facility was completely destroyed and permanently closed. CMS Goal # Heartland Kidney etwork recognizes the importance of quality of life issues for people with renal disease. Through education and technical assistance to patients and providers of care, the etwork works to increase awareness and utilization of activities and modalities that contribute to independence, rehabilitation and increased quality of life for ESRD patients. Through information provided in professional and patient newsletters, annual educational meeting, and in cooperation and collaboration with other renal related organizations, the etwork encourages all professional and patient activities that promote improved quality of care outcomes and improve quality of life. Detailed descriptions of etwork activities related to this goal are provided below. Draft submitted: May 5,

37 Heartland Kidney etwork Annual Report 36 IDEPEDECE The Patient Advisory Committee (PAC) continues to develop self-care and patient empowerment resources and tools to encourage other patients to be more involved in their care. During, the Patient Advisory Committee elected to work on the following topics: The continued development of the etwork Patient Representative program Educational resources recommendations and reviews Aids for the new dialysis patient Patient video on understanding vascular access and self-cannulation. The patient newsletter, Heartland Headlines, was published in August. A copy of the newsletter was mailed to over,4 patients homes. The newsletter addressed the following topics in regards to patient independence: Learn and Speak Up What to do if you have a complaint Talking about your wishes A guide to working with your local vocational rehabilitation Tips to help prevent medication errors In case of emergency do your part In addition to the patient newsletter, the etwork has participated in renal partner events throughout the etwork. In August, several of the etwork staff volunteered at Camp Chimer. Camp Chimer is a summer camp for children on dialysis. The etwork provided educational brochures and technical assistance to patients throughout the year. QUALITY OF LIFE The Patient Advisory Committee (PAC) continued to develop the etwork Patient Representatives (PR) pilot project. The PRs help educate and encourage patient participation in their health care to improve their overall health outcomes and quality of life. In August, Heartland Headlines, included articles on quality of life such as: Introduction of patient meetings Learn and speak up What to do if you have a complaint Talking about your wishes Kidney Transplant-Financial Assistance Programs for Living Donors Draft submitted: May 5,

38 Heartland Kidney etwork Annual Report 37 Local renal support groups Incase of an emergency. In addition to the patient newsletter, the PAC participated in planning the first patient meeting in Wichita, KS on September 5,. The planning committee developed a theme Our Lives, Our Choices: Knowledge is Power. Over patients and family members attended the meeting to learn and share patient perspectives about various treatment modality options and making the most of their in-center dialysis experience. Five PAC members actively participated as speakers during the Patient meeting. On October 3, the etwork hosted the second patient meeting in Des Moines, IA. A total of 45 patients and family members attended the meeting and four PAC members participated as speakers. VOCATIOAL REHABILITATIO Vocational rehabilitation (VR) can be defined as the process of facilitating an individual in the choice of, or return to, a suitable vocation. When necessary, assisting the patient to obtain training for such a vocation. Vocational rehabilitation can also mean preparing an individual regardless of age, or physical condition to cope emotionally, psychologically, and physically with changing circumstances in life, including remaining at school, work, or a work equivalent (homemaker). Even being able to do pleasurable activities would be considered renal rehabilitation. Creatively work with your patients to help them obtain their highest level of activity. In August, Heartland Headlines included an article entitled A guide to working with your local vocational rehabilitation. Each year Heartland Kidney etwork collects vocational rehabilitation data from dialysis and transplant facilities through the annual Facility Survey (CMS-744 Form). This report gathers the following information regarding vocational rehabilitation and employment (Table 8) for dialysis patients: umber of patients between the ages of 8-54 who are receiving rehabilitation services umber of patients between the ages of 8-54 who are employed full or part time umber of patients between the ages of 8-54 who are in school full or part time This graph shows the percentage of etworks patients (by state) between the ages of 8 and 54 that were reported to have been receiving vocational rehabilitation, employed full or part time or attending school in the years 6- (based on Facility Survey data for each of these 5 Draft submitted: May 5,

39 Heartland Kidney etwork Annual Report 38 years). In, there were 43% from Iowa; 34% from Kansas; 6% from Missouri and 3% from ebraska with a 3% etwork participation. The percentage of patients involved with VR in increased 7 percent in Iowa, four percent in Kansas and one percent in ebraska. There was a decrease by six percent in Missouri. The number of patients between the ages of 8-54 who utilized VR services went up from,39 in to,3 in. It was also noted that there was a slight increase in the number of patients between the ages of 8-54 during (4,37) compared to (4,58) throughout the etwork region. TRASPLAT During the etwork continued its relationship with Explore Transplant. In April, May and June the etwork participated in a webinar series presented by a consortium on kidney transplantation. The Transplant Collaborative convened calls on April 5 th (Explore Transplant), May th (Transplant avigation) and June nd (Donor Options) hosted by etwork s, 4, 9/ and, respectively. The sessions were attended by more than 9 attendees from more than states. The etwork in the August edition of Heartland Headlines the etwork shared an article entitled Kidney Transplant- Financial Assistance Programs for Living Donors. During the Qualityet conference in Baltimore December 3-5, Katrina Dinkel, the etwork Executive Director, presented Explore Transplant & Moving to Action Consortium: Two Approaches to Addressing the Gap in Transplant Knowledge. IMMUIZATIO Although the etwork did not have a specific intervention regarding immunizations during contract year, the importance of immunization was discussed in several programs or articles distributed by the etwork. On May 4, the Executive Director and Quality Improvement Coordinator attended the Iowa Health Care Partners Stakeholders meeting hosted by the Iowa Foundation for Medical Care (IFMC) to identify opportunities and promote collaboration. Information was presented on current IFMC activities. Breakout sessions included Hospital Acquired Infections, Healthcare associated conditions, and population health (immunizations, screening, etc.) Care Transitions was also discussed. The monthly eewsletter included such topics as: ews Flash-ow is the Time to Get Your Flu Shot! and What You eed to Know...Hepatitis B Virus (HBV). In December the etwork distributed information regarding ational Influenza Vaccination Week (IVW). This is a national observance that was established by the Centers for Disease Control and Prevention (CDC) in 5 to highlight the importance of continuing influenza vaccination as well as fostering greater use of flu vaccine after the holiday season into January and beyond. For the - Draft submitted: May 5,

40 Heartland Kidney etwork Annual Report 39 season, IVW is scheduled for December 4- and s events encouraged everyone 6 months and older to Get the flu vaccine, not the flu. CMS Goal #3 The etwork maintained consistent efforts throughout to assist facilitate and educate ESRD patients and providers in resolving beneficiary complaints and grievances. Central to this goal was the process of improving patients perception and experience of care. This was achieved by providing educational information to patients, implementing educational programs for providers, conducting trend analysis of reported situations to detect patterns of concern and developing etwork-specific policies and procedures for dealing with patient complaints. PATIET PERCEPTIO OF CARE Patient Advisory Committee (PAC) The etwork maintained a Patient Advocacy Committee (PAC), made up of patient volunteers from Iowa, Kansas, Missouri and ebraska. PAC members serve on each of the etwork boards and Committees. Mission Statement: The mission of the Patient Advisory Committee (PAC) is to educate and provide patients with perspective for dialysis and kidney transplant. Vision: To improve the quality of life for those living with Chronic Kidney Disease (CKD) and End Stage Renal Disease (ESRD) Goals: o Identify and present the needs and concerns of renal patients. o Act as a liaison between the renal population and the etwork. o Promote patient empowerment and involvement in their healthcare issues. o Develop and provide patient education to be used in the community at large. PAC members work hard to assure that the patients perspectives are carefully considered in the development of all tools, resources and etwork events for patients and professionals. In, the PAC accomplished the following: Encouraged increased patient involvement in facility and etwork activities (etwork Patient Representative program) Assisted in reviewing patient brochures and other educational resources such as: o patient newsletters, o PAC website resources, Draft submitted: May 5,

41 Heartland Kidney etwork Annual Report 4 o etwork Patient Representatives (PR) quarterly reports questionnaires and manual, o patient fistula first poster, o patients rights and responsibility poster. Provided input on topics of discussion for patient newsletters publishing. Participated in planning the patient educational meetings and as speakers during the Patient meetings held in Wichita, KS and Des Moines, IA. Began developing a Frequently Asked Question document for new dialysis patients. Held productive and successful quarterly meetings throughout The etwork values the commitment and input of our PAC members. The etwork encourages members to participate in educational organizations outside of the etwork such as ational Kidney Foundation (KF) and American Association of Kidney Patients (AAKP). Two members of the PAC are very involved in the Renal Support etwork (RS) and one member is also very involved with KF. etwork Patient Representatives (PR) Heartland Kidney etwork established the etwork Patient Representative (PR) program in October, 9. The goal of this program is to have at least one patient in each dialysis facility acting as a liaison between the etwork, facility representative (usually the social worker) and facility patients, providing educational materials as approved by their facilities to patients through bulletin boards, activities and brochures. As of December the program had 3 individuals participating in the program including the etwork Patient Advisory Committee (PAC) members. The Community Development Manger (CDM) developed a structured approach to recruiting and sustaining participation in the program. The CDM reported that there continues to be a challenge of reaching out directly to the patients especially those without phone numbers and s (majority) but they continue to utilize the social workers at the facility to assist in communicating to PR s. Dialysis facilities are encouraged to have more than one PR so that all days and shifts can be covered if specific individuals are interested. PR s are encouraged to work with their social workers to distribute educational health information to new patients, post fliers and encourage patients to learn about the resources available to them through the etwork. The program is developing more slowly than originally anticipated. The PAC continues to brainstorm on new ideas to involve patients in their healthcare. Draft submitted: May 5,

42 Heartland Kidney etwork Annual Report 4 PATIET EDUCATIOAL RESOURCES AD MEETIGS Patient ewsletter-heartland Headlines The etwork published one patient newsletter, Heartland Headlines in. The main goal of this publication is to disseminate educational information to ESRD patients to improve the independence, quality of life and rehabilitation of individuals with ESRD, and to provide opportunity for patient feedback. The newsletters were mailed directly to each patient s home (excluding those that have expressed a desire to not be contacted). PAC members contributed articles, suggested topics and reviewed the newsletter. Over,4 copies of Heartland Headlines patient newsletters were distributed in. In an effort to assist and collaborate with other renal organizations, the etwork distributed information on their educational opportunities and resources to facility representatives to make available to patients. These materials included information on ational Kidney Foundation (KF) monthly conference calls and on American Association of Kidney Patients (AAKP) Health line (poster and flyers) patient conference calls and other educational opportunities. Patient Meetings The etwork hosted the first patient meeting in Wichita, KS themed Our Lives, Our Choices: Knowledge is Power. Over patients and family members attended the meeting to learn and share patient perspectives about various treatment modality options and making the most of their in-center dialysis experience. There was also a kidney friendly cooking demonstration and patient stories that were shared. Five PAC members actively participated as speakers during the Patient meeting. The agenda included the following topics: Life beyond in-center dialysis: Home dialysis and transplant o Physician perspective o Patient perspective-pd o Patient perspective-home Hemo o Patient perspective-transplant Let s Get Cookin!: Dialysis Friendly snack demo and taste testing Maximizing your dialysis experience: In-center self care o Physician perspective o Patient perspective Ask the experts: Patient and Professional Panel The etwork hosted the second patient meeting in Des Moines, IA themed Our Lives, Our Choices: Knowledge is Power. A total of 45 patients and family members attended the meeting to learn and share patient perspectives about various treatment modality options and making the most of their incenter dialysis experience. There was also a kidney friendly cooking demonstration and patient stories Draft submitted: May 5,

43 Heartland Kidney etwork Annual Report 4 that were shared. Four PAC members actively participated as speakers during the Patient meeting. The agenda included the same topics as the Wichita, KS meeting but not necessarily the same speakers. COMPLAITS GRIEVACES AD OTHER COTACTS etwork Contacts Processing Throughout, the etwork was available to receive complaints, grievances and other contacts, such as facility or patient inquiries, on a daily basis through phone calls, and regular mail. The ESRD etworks continue to use the etwork Contact Utility nationwide. Review of a grievance involves a CMS-specified investigation process that includes a grievance determination, due process for all parties involved and a final written report. The following is an overview of the etwork s grievance procedure, which is also available on the etwork website. The formal Grievance process must be completed within 9 calendar days of receipt. A facility visit may be necessary at any time during this process depending on the nature of the complaint. Matters serious enough to be an immediate threat to the patient s or other patients health and safety are referred immediately to the appropriate State Survey Agency. If care problems are found, the Medical Review Board (MRB) may request a Corrective Action Plan (CAP) from the facility. If the facility is not successful in correcting the identified problem within the time frame of the CAP, the MRB may recommend that CMS sanction the facility. There is an appeal process available if a grievant is not satisfied with the findings of the etwork. The etwork continues to encourage patients and facilities to first attempt to collaborate with each other on solutions to quality of care issues unless immediate jeopardy is determined or the caller indicates being uncomfortable with addressing the issue(s) directly with facility staff. All contacts received at the etwork are documented in the etwork Contact Utilities data base which is utilized to analyze trends. Complaints and Inquiries The etwork received a total of 873 beneficiary and facility staff calls in. A majority of the calls 48/873 (55%) were regarding facility concerns and inquires related to information management and CROW Web details as well as the etwork annual educational conference. The etwork also reviewed every patient complaint received during in order to identify themes and trends. Patient complaints fell into the following categories: Treatment Related Staff Related Patient Transfer/Discharge Draft submitted: May 5,

44 Heartland Kidney etwork Annual Report 43 Transportation Physical Environment This chart provides a summary of beneficiary complaints (35) processed in. Complaints and grievances originated from different facilities in the four-state region. Calls received represent rural, suburban and urban settings. There were a total of 68 facility concern calls addressed at the etwork in. This is an increase of 44% over. The etwork observed a trend in the number of facility concern calls received relating to verbally and physically abusive patients during the past year. Most callers associated these concerns with an increase in the number of drug seeking behaviors and mental health related illnesses identified with patients that may or not have been addressed yet. Involuntary Discharges The Conditions for Coverage, released October 4, 8, provide a detailed summary of involuntary discharge regulations. Facilities are strongly encouraged to review and become familiar with the conditions ( (V766, V767). Although some involuntarily discharged patients are accepted into other area dialysis facilities, a number of patients move out of the area to find placement elsewhere. Additionally, there are a number of patients who, even with assistance from the etwork and other entities, are unable to find placement in an outpatient setting and must seek dialysis services through local emergency departments. Through the etwork Contact Utility (CU) database, the etwork internally tracks involuntarily discharged patients at three and six month intervals to determine readmission and mortality status, after all attempts toward placement have failed, or patient has lost contact. The graph below depicts Draft submitted: May 5,

45 Heartland Kidney etwork Annual Report 44 information the etwork has gathered regarding this small but growing population of patients involuntarily discharged in the etwork region during. The etwork received notice of and processed a total of 5 involuntary discharges during the reporting period. Throughout the year, the etwork noted a trend in increased physician initiated discharges. Discharges originated from different patients and various facilities in the four states region. This diagram provides the total percentage of discharges reported to the etwork in based on the reasons for discharge. As noted above, reasons for discharge varied from quarter to quarter throughout the year but a noted trend in physician discharges is quite vivid. During Q 8.6%, Q 66.7%, Q3 %, and Q4 75% of the discharges were physician initiated discharges for non-compliance reasons which is not an applicable reason for discharge in the Conditions for Coverage. Majority of the discharges were observed to have originated from Missouri followed by Kansas and Iowa respectively. Based on the etwork s demographics and patient residents, Missouri has the greatest dialysis patient population, followed by Kansas, thus the significant variance in percentage of discharges reported. Patient Placement after Discharge The etwork tracked patients disposition at the time of discharge and found out that 46.7 percent of those discharged had been admitted another facility; 3.3% of patients had to no Draft submitted: May 5,

46 Heartland Kidney etwork Annual Report 45 outpatient facility to accept them and were dialyzing through the hospital emergency room; while 6.7% of the discharged patients whereabouts were unknown at the time of discharge. Throughout the year, the etwork recommended facility staff contact the etwork at the initial conflict point to receive guidance and suggestions to prevent issues from escalating, leading to patient involuntary discharges. Facility staff members were provided with educational tools and advice on how to manage challenging patient situations. Callers were recommended to utilize effective assessment, care planning, interventions, and collaboration with patients in order to successfully manage challenging situations. Facility staff was encouraged to reference the Decreasing Dialysis Patient-Provider Conflict (DPC) and the Guide to Care Agreement materials provided by the etwork and become very familiar with the Conditions of Coverage. The etwork reviewed the issue(s) with facility staff and reviewed the actions/interventions taken to address the situation and potential outcomes of the actions/interventions. The etwork worked with the affected facilities to explore if actions, other than discharge, might be utilized. The etwork standard encourages the training of staff in a conflict management model such as the Decreasing Dialysis Patient/Provider Conflict (DPC) model and to conduct and document this training annually. Facilities are instructed to accurately report all involuntary discharges to the etwork, and are reminded that all involuntary discharges are an option of last resort. The Patient Services Department continued to track reported involuntarily-discharged patients to determine the number and identity of patients that returned to an outpatient dialysis facility within 6 months and patient mortality at 3-month and 6-month intervals. Data gathered during this activity was presented to facility staff members in activities aimed toward the prevention of involuntary discharges. Through the early engagement of the facilities the etwork has been able to avert several discharges during the calendar year. There were no averted discharges during the st and 4 th quarter. During quarter the etwork. percent of the total potential discharges for the year and quarter 4 saw a 5.6 percent of averted discharges. Involuntary Discharge Trending (7-) The review of demographics of discharged patients showed that when compared to the expected outcomes for age, gender and race the following categories were over-represented (i) the 8-44 year old age, (ii) males, and (iii) blacks. In, a total of 5 involuntary discharges were processed. The etwork noted a decrease in male patients discharged from facilities. A total of 5% of discharged patients were male, with an increase in the number of female discharges rising from 3% last year to 5% in. Fifty percent of discharges were between 8-44 years old which was a decline from the reporting. Fifty Draft submitted: May 5,

47 Heartland Kidney etwork Annual Report 46 percent of discharged patients were represented by black/african American patients and 4.9% were white patients which was a 3.9% increase compared to reports. Hospital staff and facility staff primarily contacted the etwork about the difficulty in finding placement for a patient at a dialysis facility. Verbal/written abuse and physical abuse were the most reported as the reason for discharge. Placement barriers reported to the etwork indicated that behaviors were the most frequent category reported. The table (above) provides a summary of involuntary discharges reported to the etwork involuntary discharges activities for the last five years (7, 8, 9, and ). A summary is provided based on the reporting period, total number of discharges reported and a further breakdown is provided to give an analysis of discharged patients gender, race and age. This figure provides a visual graphic depicting the Heartland Kidney etwork s involuntary discharges activities for the last five years. An overall decrease in involuntary discharges was observed in and may have an effect on the overall summary. etwork Proactive Activities During, The etwork collaborated with facilities based on patient complaints and concerns. These facilities were requested to develop and implement staff training in areas of skills competency, professionalism including boundaries, patient-centered care, communications and sensitivity skills, improved documentation, care planning and patient safety. Facilities were encouraged to look for trends in the data they collect, share results of their patient satisfaction surveys with the patients, involve patients in finding solutions to problems and implement solutions in a timely manner. Suggested proactive measures included: use of patients as leaders and mentors to help patients and staff identify and resolve concerns; keep a suggestion box in waiting room; and use the facility bulletin boards, newsletter, etc. to provide patients advance notice of facility changes that will affect them and, as a final measure, request a etwork on-site visit. Facilities submitted written summaries of action plans after receiving complaint notifications from the etwork. Facilities have also provided intervention summaries and reported complaints have been reviewed during monthly QAPI meetings. Draft submitted: May 5,

48 Heartland Kidney etwork Annual Report 47 On a quarterly basis, the etwork provided the State Survey Agencies with a listing of the facilities reporting involuntary discharges to the etwork to compare with those that have contacted the State Survey Agency as well. This is an ongoing collaborative activity to ensure accuracy in reporting. Monthly contacts summary reports were provided to the Contracting Officer Representative. Decreasing Dialysis Patient Provider Conflict (DPC) In, the DPC toolkit and materials remained the gold standard for addressing patient-provider conflicts. From time to time, issues arise in the dialysis setting which are difficult for the staff to handle and for patients to understand. When conflicts arise, the DPC methodology provides step by step instructions, suggestions and tips on how to manage difficult situations. The etwork shared information on DPC with facilities on the etwork website and offered technical assistance in the staff newsletters. Copies of the DPC resources were mailed to facilities upon request. Facilities are counseled to utilize the DPC resources and tools. Patient Services Staff conducted offsite training upon request by dialysis organizations. The DPC toolkit is included in the 5-Diamond Patient Safety Program and can be accessed online. During the April 8 th Board of Directors meeting etwork staff proposed a process that would require facilities with patient concerns to utilize the Decreasing Patient Provider Conflict (DPC) educational resource to train their staff members. The Board gave approval of the required process and recommended that facilities with patient complaints/concerns train their staff on this module once a year. It was also recommended that if a facility has more than one patient complaint and or involuntary discharge, the etwork staff would provide onsite DPC training to the facility. This process was also brought before the Medical Review Board on April 5, and received approval from the full MRB. The process was implemented beginning in June of. Analysis of the intervention will not be available until. Identifying and Reducing Healthcare Disparities Examining health care disparities is an integral part of improving health care quality. Health care disparities are the differences or gaps in care experienced by one population compared with another population. As the ational Healthcare Quality Report (HQR) has shown, Americans too often do not receive care that they need or they receive care that causes harm. The ational Healthcare Disparities Report (HDR) shows that moreover, some Americans receive even worse care than other Americans. The quality of health care is different for different people. Within the scope of health care delivery, these disparities are due to differences in access to care, provider biases, poor provider-patient Draft submitted: May 5,

49 Heartland Kidney etwork Annual Report 48 communication, poor health literacy, and other factors. The adequacies of dialysis treatments, as well as, the number of patients on the waitlist for kidney transplantation have been focus areas of the HQR in recent years. Variations by age, sex, and ethnicity have been identified and continue to be examined. Dialysis centers are encouraged to examine their patient demographics to determine if there are any healthcare disparities present and then perform root cause analysis and other quality improvement methods to overcome any barriers to equality in healthcare that are identified. With the calendar year of being the first year of the new Quality Incentive Program (QIP) measures, the etwork, at the direction of the Contracting Officer Representative, began tracking complaints and facility concerns as they pertain to the QIP. Some of these may lead to unintended consequences and health care disparities. The tracking began in the third quarter of. The etwork has tentatively identified four Beneficiary Concerns and 7 Facility Concerns related to the QIP. The chart below indicates the categories; a total number of 3 contacts received were identified as being related to the QIP. Common QIP concerns include 64.5% () on-adherence calls with schedule/cut treatments, 9.4% (6) on- Adherence intent to discharge or not admit, 6.5% () Supply issues, and 3.% () each for General Coverage concerns (financial), Medication Coverage and Lost to follow up. In response to an increase in the number of behavioral issues seen in the patient population during, the etwork began tracking Involuntary Discharges that may have a Mental Health issue or related issue such as Chemical/Substance Abuse or Prior IVD. The table to the right indicates that over 5 Draft submitted: May 5,

50 Heartland Kidney etwork Annual Report 49 percent of IVDs had either a diagnosed or suspected mental health concern. Twenty percent of IVDs had an IVD at a prior facility. The etwork will continue to monitor the mental health issues as it may relate to a health care disparity. In summary, the etwork was able to reach out and help improve patients perception and experience of care. The etwork was able to achieve these outcomes by providing educational information to patients, implementing educational programs for providers, conducting trend analysis of reported situations to detect patterns of concern and developing etwork-specific policies and procedures for dealing with patient complaints. CMS Goal #4 Heartland Kidney etwork has over the years continued to collaborate with the dialysis community. Developing and maintaining cooperative relationships within the renal community is a key aspect of quality improvement and is critical to the achievement of the strategic goals of the etwork program. The 8 Conditions for Coverage specifically address collaboration, stating that providers must cooperate with the ESRD etwork in fulfilling the terms of the current SOW and that each facility must participate in ESRD etwork activities and pursue etwork goals. Throughout, the etwork worked diligently to foster new relationships and strengthen existing ones. The etwork has strong partnerships at the local, state and national level, which span all affiliations and disciplines and include key stakeholders from both the renal and non-renal community. The following provides an overview of collaborative activities conducted by the etwork in support of the CMS ational goal. COLLABORATIO WITH PROVIDERS AD FACILITIES Large, Independent and Small Dialysis Organizations The needs of large dialysis organizations (LDO) are different from those of small dialysis organization or independently owned units. The large organizations have policies and procedures covering virtually all aspects of dialysis care. They provide many internal tools, resources and quality improvement materials for use by their company. The etwork provides technical assistance as well as support that can complement the activities and strategies of the LDO toward meeting their company goals and expectations. Independently owned dialysis facilities do not have the same level or availability of management resources and tools that the large dialysis organizations have. The etwork offers hands-on quality training to any facility that may require it. In, the etwork Quality Improvement Department continued an initiative The CQI Road show. The QI department continues to collaborate with LDOs and SDOs to improve their understanding of quality processes. During the spring of, the etwork Draft submitted: May 5,

51 Heartland Kidney etwork Annual Report 5 began checking out a Cannulation Kit to any facility needing cannulation training. The kit has been used by facilities, both LDO and SDO. The etwork collaborated with multiple entities in response to the Joplin, MO tornado. An EF-5 tornado struck the city of Joplin, MO on Sunday, May,. There were three facilities serving a total of patients in Joplin. FMC-Joplin West 654 (4 patients, 3 chairs) was severely damaged and has been permanently closed. FMC-Joplin East (75 patients, 9 chairs); and Freeman Dialysis 637 (94 patients, 7 chairs)are both remain open. The FMC-Joplin West patients have been transferred to the FMC-Joplin East unit and/or other facilities as requested by patients. In the midst of the tragedy, there was a coordinated effort by both remaining facilities to work together to meet the needs of all the dialysis patients, helping both facilities to re-open by Tuesday, May 4,. This was done by sharing resources as well as making back-up plans for dialysis with neighboring units: Miami, Oklahoma; Monett, Missouri; and Pittsburg, Kansas. In the days following the Joplin tornado, the etwork assisted with communication efforts by corresponding with the Disaster Contacts of the impacted facilities, providing information and status updates to Centers for Medicare and Medicaid Services (CMS), the Missouri Department Health & Senior Services (State Agency representative), KCER, ESRD etwork 3, Freeman Dialysis Center, Fresenius Medical Services and neighboring dialysis facilities in Arkansas, Kansas, Missouri and Oklahoma. The consistent communication and efforts during this disaster assisted the facilities in responding to the direct local needs while utilizing the resources and contacts the etwork had available. In addition, the lessons learned were shared with the renal community within the etwork. State Survey Agency During the etwork participated in quarterly teleconferences with the State Survey Agencies. The teleconferences allowed for discussions on common citations, involuntary discharges, complaints and grievances, etwork quality improvement initiatives including Fistula First and other updates pertaining to quality of care and conditions for coverage. The etwork provided the State Survey Agencies facility specific information upon request and reviewed survey results. Missouri Kidney Program (MOKP) During the etwork attended quarterly meetings with MOKP and provided the members with an update on etwork activities and other information germane to the renal community. The Executive Director is an Ad Hoc member of the Advisory Committee. The relationship between the MOKP and the etwork is long standing and continues to provide more strength to each through our collaborative activities. Draft submitted: May 5,

52 Heartland Kidney etwork Annual Report 5 Kansas Kidney Coalition (KKC) The etwork has been involved with the Kansas Kidney Coalition (KKC) since 7 and continues to support its grassroots efforts towards providing additional support for ESRD/CKD patients living in Kansas. Current activities of the coalition include Kidney Awareness Day at the Capital, kidney disease screenings, and legislative activities. Heartland Kidney etwork, however, does not participate in the legislative activities. Heartland Chronic Kidney Disease (CKD) Coalition During the January 3, conference call various issues were discussed and new partners were also explored to address the particular issue and meet the needs of the coalition. Members of the etwork staff facilitate CKD coalition activities and meetings. During the second quarter of the year there was no meeting scheduled due to the uncertainty of the QIO (Primaris) th Scope of Work. Although MO/Primaris is no longer engaged in CKD activities, additional time is being spent to consider future opportunities for collaboration between the etwork and QIO, including Care Transitions. ational Kidney Foundation (KF) The etwork staff works closely with the local KF organizations as members of the educational planning committee. The etwork staff participated in KF national clinical educational meeting. The etwork offered vendor space to the KF at the etworks annual educational conference for. Other Collaborative Activities In May the Executive Director and Quality Improvement Coordinator attended the Iowa Health Care Partners Stakeholders meeting hosted by the Iowa Foundation for Medical Care (IFMC) to identify opportunities and promote collaboration. The QID attended the State Level HAI training in Dallas, TX in September. During the session Joseph Scaletta, Infection Preventionist, State of Kansas Department of Health and Environment began collaborating with the etwork to train dialysis facilities on the use of HS. The etwork began building collaboration with Mental Health Services in each of the four states and the ESRD facilities by collecting a database of the county mental health clinics, contacting personnel and identifying transportation services to refer renal patients. Two webinar sessions were held in the month of September on avigating the Mental Health system in ebraska and Kansas. Missouri and Iowa sessions were scheduled during for a later date. Draft submitted: May 5,

53 Heartland Kidney etwork Annual Report 5 Pediatric Dialysis Units The chart to the left provides a summary of the pediatric prevalent and incident patients at the etwork as of December 3, as reported in the Annual survey data (table,, 6 and 7). As of December 3,, there were a total of pediatric prevalent patients compared to 4 in. There were 78 reported incident patients compared to 7 in. Forty-six pediatric patients underwent kidney transplant compared to 4 in and four deaths were reported during compared to two in. According to the table below (representing Annual survey report data), there were pediatric prevalent patients in the etwork during. There were patients from IA, 9 from KS, 4 from MO, 3 from E and 7 from other out of etwork regions. The majority (4) of the pediatric population was between the ages of 5-9 yrs followed by 9 who were between the ages of 5-9 years old. The etwork will continue to collaborate with pediatric facilities and care providers to address the needs of the pediatric patient population. Peritoneal Dialysis Units and Dialysis Centers in Long Term Care Facilities There are dialysis centers that serve only peritoneal dialysis patients in the four-state region. During, the etwork included peritoneal dialysis clinical goals in the etwork goals. Peritoneal dialysis is a wonderful option for suitable candidates as it promotes independence as well as a more liberal diet and fluid intake. Throughout, the etwork continued to provide services to the five dialysis facilities in the St. Louis, Missouri area located in long term care facilities. Basing a dialysis center within a long term care facility provides a special need population with convenient dialysis services. Draft submitted: May 5,