Life Plan

Patient Involvement in Developing a Life Plan

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 Centers for Medicare & Medicaid Services (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."

Tools & Resources

Eight Dimensions of Patient Centered Care

  • Module One: Patient Preference and Emotional Support: Video | Slides
  • Module Two: Coordination of Care and Family and Friends: Video | Slides
  • Module Three: Information and Education and Continuity and Transition: Video | Slides
  • Module Four: Physical Comfort and Access to Care: Video | Slides

My Dialysis Plan

The UNC Kidney Center created My Dialysis Plan in collaboration with patients, clinic personnel, and medical providers to align dialysis care and treatment with patient identified priorities using a patient-centered approach.

  • All resources related to this program can be accessed and downloaded here.

Additional Guidance

Hospitalization Avoidance
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