The Centers for Medicare & Medicaid Services worked with 21 Medicare Accountable Care Organizations (ACOs) and End-Stage Renal Disease Seamless Care Organizations (ESCOs) participating in the Shared Savings Program, Next Generation ACO Model, and the Comprehensive ESRD Care Model to identify promising practices and innovative strategies for coordinating care for Medicare beneficiaries.
Specifically, the ACO Care Coordination Toolkit focuses on care coordination for Medicare beneficiaries who:
- Recently received care in an emergency department,
- Require treatment in a skilled nursing facility,
- Have recently been discharged home after a hospital or emergency department visit,
- Have been diagnosed with a chronic condition or have a complex medication regimen, or
- Have conditions affected by the social determinants of health.
Working with the same methodology, CMS also has released the ACO Beneficiary Engagement Toolkit which highlights strategies used by ACOs and ESRD Seamless Care Organizations (ESCOs) to engage beneficiaries. Specifically, the toolkit explores how ACOs and ESCOs:
- Engage beneficiaries in ACO governance,
- Elicit beneficiary and family feedback,
- Support beneficiaries in self-care management,
- Enhance beneficiary communication in the clinical setting, and
- Communicate with beneficiaries about the ACO as a value-based care organization.
These toolkits are part of a broader series of toolkits designed to educate the public about the strategies ACOs use to provide value-based care while also providing actionable ideas to current and prospective ACOs to help them improve or begin operations.
For more information on the toolkits and case studies please visit the ACO General Information webpage.
The Kidney Innovation Accelerator (KidneyX) is a public-private partnership between the U.S. Department of Health and Human Services (HHS) and the American Society of Nephrology (ASN) seeking to improve the lives of the 850 million people worldwide currently affected by kidney diseases. KidneyX aims to accelerate breakthroughs to promising new technologies for people with kidney diseases by addressing barriers innovators commonly identify as they develop new products for the prevention, diagnosis, and treatment in kidney care. To do this, KidneyX hopes to create a better collaborative relationship among patients and innovators.
KidneyX Patient Innovator Challenge (Prize Competition)
The Patient Innovator Challenge, funded by the National Kidney Foundation, is looking for ideas and fixes that people living with kidney diseases have developed through their own experiences and ingenuity. In this competition there are two submission categories:
- Category 1: “Solutions in Practice,” which are solutions already tried or put into practice
- Category 2: “New Ideas,” which are solutions that have not yet been created or tried.
Anyone can apply for the competition and some key areas submissions may focus on are how to manage the side effects of dialysis or transplant treatment, ways to gain patient independence, successful diet and fluid regimens, techniques to increase physical activity, and methods which help sustain family and social life or improve overall quality of life.
Up to 25 winners will be awarded – 10 winners in Category 1 will receive $4,000 each, and up to 15 winners in Category 2 will receive $2,000.
Submissions are due by 5:00 ET on September 16, 2019. For more information, go to https://www.kidneyx.org/WhatWeDo/PrizeCompetitions/patientinnovatorchallenge
My Employment Options will present a March 21, 2019 Resume Tips Workshop webinar. Topics include Formatting Tips For Resumes, How To Create Work At Home Resumes, How to Create Onsite Job Resumes, Gaps in Employment, and Career Changes.
Register at https://www.myemploymentoptions.com/webinar-registration-form/.
My Employment Options also offers free job placement services for recipients of SSDI and SSI, including work at home. See https://www.myemploymentoptions.com/apply-now/ for details.
AAKP will present a January 23, 2019 HealthLine webinar on Taking Care of Yourself While Taking Care of Your Loved Ones – Coping Strategies for Kidney Patient Caregivers. For details and registration see https://register.gotowebinar.com/register/7534192719300817923.
The Centers for Medicare & Medicaid Services (CMS) has incorporated in the 2018 transplant quality improvement activity (QIA) a series of standardized steps toward transplant. According to the 2012 Clinical Journal of American Society of Nephrology article, “Impact of Navigators on Completion of Steps in the Kidney Transplant Process: A Randomized, Controlled Trial,” these steps were first defined and performed in 23 hemodialysis facilities in Ohio. The steps are: (1) Suitability for Referral to Transplant Center; (2) Interest in Transplant; (3) Referral Call to Transplant Center; (4) First Visit to Transplant Center; (5) Transplant Center Workup; (6) Successful Transplant Candidate; (7) On Waiting List or Evaluating Potential Living Donor.
Research has identified that the guidance offered by a transplant navigator –or mentor- helps patients move further and faster through the seven steps than they would without a navigator. If you are interested in starting a Peer Mentorship Program at your facility, contact the Network.
In 1988, researchers from the Harvard Medical School, on behalf of the Pickler Institute, developed the model known as the Eight Dimensions of Patient-Centered Care. The model challenges clinicians to cultivate a better understanding of a patient’s illness and address their needs. Secondary to knowledge gain, patients are viewed as equals to clinicians when making decisions about their healthcare.
A component of patient-centered care includes the concept of shared decision making or a process where patients work alongside their clinicians to make decisions about their treatments and care plans. Clinical evidence is reviewed to weigh the risks and outcomes associated with the decisions keeping a focus on the patient’s preferences and values. Benefits that come from patients engaging in the shared decision process include understanding their health along with the pros and cons of different options, being better prepared to collaborate with their healthcare team, and most importantly they are more likely to follow through on their decisions. For more information and tools on shared decision making, visit the New England Journal of Medicine at www.nejm.org and the National Learning Consortium at www.healthit.gov.
The IPRO ESRD Network program provides technical assistance to facilities in multiple ways including education and resources to support patient engagement at the facility level. One way the Network encourages patient engagement is through the assistance we offer to local facilities in implementing or learning more about available peer mentorship/ambassador programs.
According to an article published in 2015, “Potential Impact of Peer Mentoring on Treatment Choice in Patients with Chronic Kidney Disease: A Review,” written by Nasrollah Ghahramani MD, FACP, FASN, peer to peer programs have shown to help patients become more involved in their health care. Patients who work with a peer as a mentor are able to make more informed decisions about their dialysis treatment options and are better informed about transplant processes. Being informed about health care decisions by peers with shared experiences can build self-confidence which then leads to overall better health outcomes.
To read more about Ghahramani’s findings, click here.
To learn more about patient programs offered by your Network or local agencies, contact your ESRD Patient Services Department. Our Patient Services Team is here to assist with resources on the benefits of implementing patient peer programs or other patient support programming at your facility.
For many years, Vocational Rehabilitation (VR) and Employment Networks (EN) were thought of as programs for individuals without a disability. Today, more people with disabilities are finding out that is not true and that VR/EN is more than just about employment. In the article titled “Vocational Rehabilitation for People with Disabilities” Gloria K. Lee describes employment as a fundamental right for people with disabilities. She goes on to define VR from an intervention perspective describing the complex process of VR and the different components involved. By reading this article you will understand the importance of assisting ESRD patients in obtaining in VR/EN services to improve their quality of life.
Have any of your patients or their caregivers/family members shared with you their feelings about not being heard?
Has a patient ever shared an idea they felt would be useful for others with ESRD?
If so, we know you’ll understand the value of engaging such individuals in efforts to improve patient care. We need your help!
The Network has convened a group of Patient Subject Matter Experts (SMEs) to provide patient perspective and feedback to the Network on educational materials, quality improvement projects and other issues that relate to our work in improving care to ESRD patients. Please consider nominating patients, transplant recipients, and family members/care partners who are interested in sharing their talents and ideas with other SMEs in the Network.
What do SMEs do? Ultimately, they help Network staff understand what is important to patients, share useful ideas and experiences, and foster Network initiatives at their own dialysis facility and transplant center. Their efforts focus on providing feedback on Network quality improvement activities related to infection prevention, transplant referrals, home dialysis training, vocational rehabilitation, and patient engagement.
For more information, please contact your local Network.
The Department of Health and Human Services (HHS) National Quality Strategy (NQS) is a national effort to align public- and private-sector stakeholders to achieve better health and healthcare for all Americans. It was developed “through a transparent and collaborative process with input from a range of stakeholders. More than 300 groups, organizations, and individuals, representing all sectors of the health care industry and the general public, provided comments.”
The Centers for Medicare & Medicaid Services (CMS) contracts with End Stage Renal Disease (ESRD) Networks to implement the NQS principles and HHS Secretary’s priorities in the ESRD community. Starting in December 2017, Networks will launch a set of new quality improvement activities, data reporting requirements, and educational programs that reflect updated priorities and goals.
HHS Secretary’s Priorities
- Reform, Strengthen, and Modernize the Nation’s Health Care System
- Protect the Health of Americans Where They Live, Learn, Work, and Play
- Strengthen the Economic and Social Well-Being of Americans Across the Lifespan
- Foster Sound, Sustained Advances in the Sciences
- Promote Effective and Efficient Management and Stewardship
- Empower patients to make decisions about their health care
- Usher in a new era of state flexibility and local leadership
- Support innovative approaches to improve quality, accessibility, and affordability
- Improve the CMS customer experience
Part of the responsibility of the interdisciplinary team (IDT) is to include patients, and if requested, their care partners and family members in both developing/setting goals and reviewing the patient plan of care.
Is it acceptable to hold a plan of care meeting with the IDT and the patient, their care partner or family members (if requested) via telephone conference? As stated in the CMS Interpretive Guidance for the Conditions for Coverage for End-Stage Renal Disease Facilities, the answer is “yes.”
“A substitute mechanism for a team conference needs to facilitate discussion among team members about the information gathered from the comprehensive patient assessment and provide the opportunity for team coordination and development of an effective, individualized plan of care for the patient to ensure the desired outcomes are achieved. To facilitate full team participation in conferences, any member, including the patient, may participate through telecommunication.”
CMS Interpretive Guidelines (see page 205): http://esrd.ipro.org/wpcontent/uploads/2017/08/InterpretiveGuidelines.pdfÂ
For more information on the regulations on plans of care, see the CMS Conditions for Coverage for end-stage renal disease facilities. Subpart C – Patient Care: https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol5/xml/CFR-2011-title42-vol5-sec494-90.xml