1. Entering A New Era Together March 7, 2013 NEW Expectations, Activities and OPPORTUNITIES

2. Today's presenters  Glenda Harbert, RN, CNN, CPHQ Executive Director  Anna Ramirez, MPH, CPH Community Outreach Coordinator  Kelly Shipley, RHIA Quality Improvement Director  Treneva Butler, LCSW Patient Services Director  Nathan Muzos, BS Information Management Director

3. Today’s Objectives for Participants Identify CMS’ vision for ESRD oversight Describe the projects in the Network contract Explain the role of the dialysis and transplant facility in the new projects Offer input and feedback on the Network projects (via feedback at the end)

4. US Department of Health and Human Services (HHS) Created National Quality Strategy (NQS) to promote quality health care focused on the needs of patients, families and communities Identified 3 Aims for Healthcare – Better Care – Healthy People and Communities – Affordable Care

5. US Department of Health and Human Services (HHS) The Affordable Care Act sets America on a path toward a higher quality health care system so we stop doing things that don’t work for patients and start doing more of the things that do work. HHS Secretary Kathleen Sebelius

6. Centers for Medicare & Medicaid Services (CMS) CMS, 1 of 11 HHS Divisions, administers the ESRD Medicare Program CMS’ Aims for the ESRD Program 1.Better Care for the Individual through Beneficiary and Family Centered Care 2.Better Health for the ESRD Population 3.Reduce ESRD Costs Improving Care USRDS 2012 Annual Report

7. Centers for Medicare & Medicaid Services (CMS) CMS uses two external groups to provide ESRD oversight – State Survey Agencies – ESRD Networks CMS contracts with 18 ESRD Networks to oversee ESRD care nationally Network Contract/Statement of Work describes projects required to accomplish the 3 aims and the national quality goals (i) Standard: Relationship with the ESRD network. The governing body receives and acts upon recommendations from the ESRD network. The dialysis facility must cooperate with the ESRD network designated for its geographic area, in fulfilling the terms of the Network’s current statement of work. Each facility must participate in ESRD network activities and pursue network goals. §494.180

8. Centers for Medicare & Medicaid Services (CMS) CMS Chief Operating Officer and Acting Administrator Marilyn Tavenner The Networks are uniquely positioned to ensure full participation of the ESRD community in achieving the AIMS of the NQS. The Networks shall assist providers in adjusting to the heightened focus on patient and family centered care, aiming to help them optimize customer service.

9. ESRD Network of Texas, Inc. Nonprofit organization, volunteer Boards ESRD NW of TX, Inc. holds the contract with CMS for ESRD Network #14, the state of Texas Office in Dallas The largest Network in the US based on numbers of dialysis and transplant patients 3 rd largest in number of providers 13 Staff members

10. 2012 Network Coordinating Council I nput Scan Evaluation of achieving Our Mission To support quality dialysis and kidney transplant healthcare through the provision of patient services, education, quality improvement, and information management.

11. ESRD Network 14 – New Communications Policy Most Network 14 to Dialysis Facility correspondence will be sent via email to all registered QIMS users of the facility Essential to keep email address updated in QIMS Disable accounts for personnel when they leave your facility

12. 2013 Network #14 Growth & Trends CMS Certified Facilities Facility Ownership Growth in Patient Census Patients Transplanted 2013 Network #14 Growth & Trends CMS Certified Facilities Facility Ownership Growth in Patient Census Patients Transplanted

13. NETWORK GROWTH Number of Medicare Certified Providers 44 facilities awaiting Medicare Certification at end of Feb. 2013

14. National Chain Ownership TX Dialysis facilities Feb. 2013

15. Number of Patients 12/31/12 40, 082 9,103 6,234

16. ESRD Network 14 Currently providing care and oversight for >50,000 people receiving Renal Replacement Therapies – 40,082 people on dialysis – 54.1% Male – 28.9% African American – 43.2% Hispanic – 70.1% between 50 and 79 years old

17. Themes of the New ESRD Plan/SOW Patient and Family Engagement Reducing Disparities in Healthcare Connecting communities, sharing best practices Performance-Based Measures

18. AIM 1: Better Care for the Individual through Beneficiary and Family Centered Care

19. DomainSub-Domain Vascular Access Management Reduce Catheter Rates for Prevalent Patients Support Facility Vascular Access Reporting Spread Best Practices Provide Technical Support in the Area of Vascular Access Recommend Sanctions Patient Safety: Healthcare-Acquired Infections (HAIs) Support National Healthcare Safety Network (NHSN) Establish HAI LAN Reduce Rates of Dialysis Facility Events AIM 1: Better Care for the Individual through Beneficiary and Family Centered Care

20. AIM 2: Better Health for the ESRD Population Population Health Innovation Pilot Project Reduce Identified Disparity Increase Hepatitis B (HBV), staff & Patient Influenza, and Pneumococcal Vaccination Rates DomainSub-Domain

21. AIM 3: Reduce Costs of ESRD Care by Improving Care Support for ESRD Quality Incentive Program (QIP) & Performance Improvement on QIP Measures, Support for Facility Data Submission to CW, NHSN, and/or Other CMS- Designated Data Collection System(s) Assist Facilities in Understanding and Complying with QIP Processes and Requirements Assist Beneficiaries and Caregivers in Understanding the QIP Assist Facilities in Improving their Performance on QIP Measures DomainSub-Domain

22. CMS directed organizational changes Network Council – Currently 1 representative from all Medicare Certified Facilities – Divide stat into 5 RAC regions with one representative from each Board of Directors – Non renal healthcare members – Non Healthcare members – 2 patients Bylaws revision in progress with Electronic bylaws change and election of new Network Council in next 2 months

24. AIM 1: Better Care for the Individual through Beneficiary and Family Centered Care Two Tier Approach to Patient and Family Engagement Tier 1: Engagement at the dialysis facility level to foster patient and family involvement Tier 2: Development and implementation of a beneficiary and family centered care focused Learning and Action Network to promote patient and family involvement at the Network level.

25. Patient and Family Involvement at the Facility Level Webinar on Patient Centered Care (PCC) and Patient Engagement (PE) March 22, 2013 from 12:00 – 1:15pm. Free CEUs for nurses, dietitians, social workers & technicians Registration information available: http://www.esrdnetwork.org/network/calendar.asp PCC and PE Mail Out Facility onsite visits, the Network will assess whether The QAPI program includes patient and family participation Patient and family meetings exist (patient council, support groups, vocational rehabilitation groups, new patient adjustment groups) Patients and families are involved in the governing body of the facility Patient’s involvement in plan of care meetings

26. Patient and Family Engagement – Aim 1 “In CMS’ view, most Network activities will be enhanced by the Patient’s voice” Establish a Patient Learning and Action Network (LAN) – Patient Subject Matter Experts – Family members – Dialysis Facilities – State Surveyors – Other stakeholders Patient SMEs Committed and informed patients Representative of the demographic characteristics of the Network area LAN Uses change methodologies, tools, and/or time-bounded initiatives. Engages leaders around an action-based agenda. Creates opportunities for in-depth learning and problem solving. Creates an opportunity for communities, with assistance and guidance from the ESRD Network, to harness the knowledge, skills, and abilities of community partners to reach a critical mass of the appropriate stakeholders in the community concerned with a common aim(s).

27. Aim 1-Patient and Family Engagement PE LAN will design and implement a Quality Improvement Activity (QIA) – Topic chosen by SMEs: Patient Centered Care with a focus on improving patient-provider communication – Will use a subset of ICH-CAHPS questions to measure improvement – Facilities will be selected to participate in QIA working with ~4,000 patients and show a 5% relative improvement

28. Aim 1-Patient and Family Engagement PE LAN design 2 Campaigns – Topics: New Patient Orientation Disease Management – Must impact 20% of Network population (~8,000 patients) – Must show a 10% improvement in selected measure – Begin 2 nd Quarter

29. Aim 1-Patient and Family Engagement For more information on the PE LAN please contact Anna Ramirez aramirez@nw14.esrd.net 469-916-3800 Facilities are still needed to participate! Application available online: http://www.esrdnetwork.org/professionals/index.asp

30. Patient Experience of Care – Aim 1 Formerly “Complaints and Grievances” Satisfaction survey – All grievants invited to participate – Network must maintain 80% satisfaction rate Facilities must inform patients about the Network role in grievances Network collaborates with State Surveyors on grievances

31. Aim 1-Patient Experience of Care Grievance Quality Improvement Activity (QIA) – Use grievance data to identify common trend – Select at least 5 facilities for intervention – Selected facilities must show at least 1% improvement in the measure – Project may be expanded to 100 facilities at CMS’ request

32. Patient Experience of Care – Aim 1 Facilities are expected to – Utilize ICH-CAHPS – 2013 QIP Measure – Address issues identified in ICH-CAHPS – Specifically be aware of disparities in care Network will – Promote use of ICH-CAHPS – Assist facilities with trend analysis of ICH-CAHPS – 2014: Conduct a QIA using ICH-CAHPS ICH-CAHPS In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems

33. Patient-Appropriate Access to In- Center Dialysis – Aim 1 Reduce IVD/IVT by 5% each quarter Avert 5% of potential IVD/IVT Network to analyze data to evaluate discharges for disparities in race, ethnicity, new ESRD versus established patient Network to report all actual and potential IVD/IVT, failures to place and at risk IVD/IVT Facility-generated discharge or transfer resulting in termination of services for patient. Does not include transfers due to emergency or other closure.

34. Vascular Access Management – Aim 1 Catheter Reduction – Move from a Fistula First to a Catheter Last approach – Quality Improvement Activity to decrease long- term catheter utilization begins this quarter Every facility that shows a long-term catheter rate greater than 10% in CROWNWeb is selected Selected facilities must improve monthly and meet an overall 2% reduction

35. Vascular Access Management – Aim 1 Update CROWNWeb monthly with each ICH patient’s vascular access type AV Fistulas – New CMS goal: 68% – New MRB goal: 57% – Quality Improvement Activity to increase Network AVF rate begins this quarter In conjunction with Catheter focus facilities Two tiered approach

36. 119 facilities with >10% patients with catheter >=90 days *CROWNWeb data, facilities with <11 patients excluded (n=13 facilities), pediatric excluded MRB 2/7/13

37. Patient Safety – Aim 1 All facilities participating in NHSN – Enroll – Join Network 14 NHSN Group – Enter monthly data Establish HAI LAN – Open to all facilities in the Network – Community Stakeholders National Healthcare Safety Network HAI: Healthcare Acquired/ Associated Infections

38. Patient Safety – Aim 1 HAI Quality Improvement Activity to Reduce Central-line-associated bloodstream infections (CLABSI) – Select 100 facilities working with ~2,000 patients – Selected facilities must show 5% reduction in CLABSI – Begins 2 nd Quarter

39. CMS ESRD Network Contract – Aim 2 Innovation Pilot Project - Reduce Disparities in Immunization Reducing Hospitalization Home Dialysis Placement Quality of Life

40. Innovation Pilot Project – Aim 2 Select topic with 85% of target population not meeting the desired outcome Select population group (CMS-defined) with the greatest disparity in outcomes – African American/White – Hispanic/Non-Hispanic – Urban/rural – Male/Female – 65 years old/younger than 65

41. Innovation Pilot Project – Aim 2 Select 50 facilities working with ~4,200 patients Selected facilities must increase immunization in disparate group by 5 percentage points If non-disparate group improves more than disparity group, widening the gap, project fails

42. CMS ESRD Network Contract – Aim 3 Aim 3  Reduce Costs of ESRD Care by Improving Care  Quality Incentive Program (QIP)  CROWNWeb Aim 3  Reduce Costs of ESRD Care by Improving Care  Quality Incentive Program (QIP)  CROWNWeb

43. Quality Incentive Program – Aim 3 Facility Responsibility – Submit accurate quality data – Complete QIP requirements timely – Review Performance Score Report within 5 days – Post Performance Score Certificate within 5 days – Address QIP performance issues to deliver high quality of care

44. Quality Incentive Program – Aim 3 Network responsibility – Assist patients in understanding QIP – Help facilities improve QIP outcomes – Remind facilities of due dates – Provide feedback to CMS on any adverse impact to patients and intervene to correct – Discuss QIP measures and results with State Surveyors

45. CROWNWeb – Aim 3 Enter data into CROWNWeb accurately and timely If you are a “batch” facility, make sure loaded data is correct Make sure your QIMS enrollments are up to date

46. For technical issues, contact QualityNet Help Desk at qnetsupport-esrd@sdps.org Contact Network 14 at crownweb@nw14.esrd.net Visit http://projectcrownweb.org for the latest CROWNWeb news and training modules CROWNWeb – Aim 3

47. Summary Patient/Family Engagement in all Patient-Centered Care and Policies Reduction / elimination of Disparities in Healthcare Performance-based measures

48. Summary 5 Quality Improvement Activities – Patient/Family engagement – Grievances – Decreasing Catheter Use – Healthcare Acquired/Associated Infections – Reducing disparity in Immunizations

49. Summary 2 Educational Campaigns Grievance resolution Reducing IVD/IVT CROWNWeb, NHSN, Dialysis Facility Reports QIP Tracking and Education

50. Questions? We will post a Q&A response on our Website within 2 weeks www.esrdnetwork.org Send us an email Subject line: Ask the Network info@nw14.esrd.net