Nutritional Supplement Program for Shelby County September 27, 2012

WHO WE ARE www:tennesseekidneyfoundation.org In the late 1960’s a group of visionary volunteers foresaw the need to act with a unified force. They created the Tennessee Kidney Foundation. Their vision, their goal, had seen success unequalled by any other organization. In December 2009, the National Kidney Foundation of Middle Tennessee was merged with the Tennessee Kidney Foundation to better serve the patients in Tennessee. Our main concern when we began in 2009 was with the patients in Middle Tennessee but we are excited to start expanding to West TN with this Supplement Program.

How we work across TN  The TKF has a 3 person full time staff that works with all the dialysis clinics Social Workers and Dieticians to meet the needs of the patients.  The TKF’s CEO works hard to find grants and funding to help us meet the needs of the clients across the state. She works to find grants and funding to help with the various areas.  With the Shelby County supplement grant and the Walmart grant in the rural areas of West Tennessee, TKF is happy to be helping patients in West TN.

WessCare Home Medical  TKF has been working with Metro Medical from Nashville for the Middle TN supplement Program for several years. Jim Brunner, who is our major contact there and a past board member helped us to obtain a connection with Dustin Smith at WessCare Home Medical Equipment to build a program for Shelby county.  This program will roll out on Monday, October 1, If successful it is hoped that the program will start in all of West TN by the first of next year.  A price sheet has been established by WessCare and is attached for your perusal. All orders must go through the TKF. Once the sheet is completed it will be mailed, faxed or ed to Teresa Davidson at the TKF.

WessCare Price Sheet Instructions for WessCare Price Sheet 1.Put Date at top that you are sending to TKF along with Address of Clinic where product will be delivered. 2.Fill in # Cases and total cost 3.Add Fuel Surcharge for TOTAL COST OF ORDER 4.Complete ordered by and phone number of clinic. 5.Have patient sign at bottom and complete the release statement.

Rules & Guidelines of Program  All participants in this Nutritional Supplement Grant must complete an application and return it in one of the following ways: 1. Fax to TKF: ; mail to TKF office, 95 White Bridge Road, Suite 300, Nashville, TN 3720  This application is for 1. Indigent patients that live in the Shelby County 2. Funds to be used between October 1, 2012 – June 30, Purchasing supplements for needy patients with Albumin levels less than 3.8

Rules & Guidelines of Program  At time of application Albumin rate must be noted on the application. You must also submit the latest albumin rate from labs on the monthly request form. 1. No request shall exceed a case per month per patient. A Patient may use this grant for 3 months. 2. Applications are due by the 17 th of the month. 3. Each clinic is allowed to spend $100 per month on any combination of the products listed on the order sheet. 4. Please note that only 1 case per patient can be ordered, but a clinic could have up to 3 patients using the funding each month.  The patient should have an application completed for the State Renal Program or Ross Program (when functioning). This funding is to serve as a safety net to new patients that are not on either the Ross program or the State Renal Program. If your patient cannot tolerate Ross Products please put a statement on the front of the application to this point.   You must complete the full application and show that you have signed up for the Ross Products discount cases for this patient unless otherwise noted (see # 5)   Checks will be cut to the distributor WESSCARE who will be providing the service, they will not be sent directly to patient.   Once application is approved, the TKF office will be assign a number to each patient. The order sheet will be faxed to WessCare Home Medical Equipment from the TKF office and the product will be delivered to the Clinic at the address provided on the order form. Orders not faxed from our office will not be accepted by WessCare.

Rules & Guidelines of Program  The patient should have an application completed for the State Renal Program or Ross Program (when functioning). This funding is to serve as a safety net to new patients that are not on either the Ross program or the State Renal Program. If your patient cannot tolerate Ross Products please put a statement on the front of the application to this point.  Checks will be cut to the distributor WESSCARE who will be providing the service, they will not be sent directly to patient.

Rules & Guidelines of Program  Once application is approved, the TKF office will be assign a number to each patient. The order sheet will be faxed to WessCare Home Medical Equipment from the TKF office and the product will be delivered to the Clinic at the address provided on the order form. Orders not faxed from our office will not be accepted by WessCare.

Application Forms 1. Demographic Page 2. Financial Inventory Page – SW to complete…do not give to patient to complete…. 3. Authorization of Release Medical/Financial Information 4. Change Sheet 5. Emergency Request Form

QUESTIONS & ANSWERS Teresa Davidson, CEO Tennessee Kidney Foundation 95 White Bridge Road, Suite 300 Nashville, TN