1. Confidential and Proprietary Patient Centered Care and the Triple Aims Beverly Hoek, RN, CNN Quality Improvement Director March 14, 2013

2. Confidential and Proprietary NEEDLESS TRAGEDY OF BOY, 12, WHO DIED JUST THREE DAYS AFTER DOCTORS MISSED RAGING INFECTION FROM CUT TO ARM HE GOT PLAYING BASKETBALL 'It was this lack of care and communication which resulted in Rory’s death and what we and our daughter Kathleen will live with every day of our lives. We have been handed a life sentence.'

3. Confidential and Proprietary Quality Insights Renal Network 3 “ The Network”  18 Networks throughout the US  Each State is assigned to a Network  Contract through CMS  3 Year Contract  QIRN3 - NJ, Puerto Rico and US Virgin Islands  Began a new contract in January 2013

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6. New Jersey ESRD Population 2002-2011

7. Confidential and Proprietary ESRD Patients by County  Atlantic 463  Bergen 990  Burlington 559  Camden 808  Cape May 110  Cumberland 360  Essex 1704  Gloucester 317  Hudson 857  Hunterdon 48  Mercer 345  Middlesex 845  Monmouth 782  Morris 434  Ocean 668  Passaic 736  Salem 54  Somerset 158  Sussex 67  Union 791  Warren 82

8. Confidential and Proprietary New Jersey Dialysis Facilities 1990-2012

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11. Federal Regulation § 494.180  Condition – Governance –Standard Designating a CEO or administrator…who exercises responsibility for the management of the facility and the provision of all dialysis services, including, but not limited to— Staff appointments Fiscal operations The relationship with the ESRD Network

12. Confidential and Proprietary (i) Standard: Relationship with the ESRD Network  The governing body receives and acts upon recommendations of 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 the ESRD network activities and pursue Network goals.

13. Confidential and Proprietary Sanctions  The Network has the authority to recommend to CMS that they (CMS) impose Sanctions –Close the dialysis unit –Reduction in reimbursement –CMS will not pay for any new patients on Medicare

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16. Triple Aims I.Better Care for the Individual through Beneficiary and Family Centered Care I.Better Health for the ESRD Population I.Reduce Costs of ESRD Care by Improving Care

17. Confidential and Proprietary AIM I - Domains  Patient and Family Engagement  Patient Experience of Care  Patient –Appropriate Access to In-Center Dialysis Care  Vascular Access Management  Patient Safety: Healthcare-Acquired Infections (HAIs)

18. Confidential and Proprietary AIM II - Domain  Population Health Innovation Pilot Project –Increase Hepatitis B (HBV), Influenza, and Pneumococcal Vaccination Rates

19. Confidential and Proprietary AIM III- Domain  Support for the ESRD Quality Incentive Program (QIP) and Performance Improvement on QIP Measures  Support for Facility Data Submission to CROWNWeb, NHSN, and other CMS- Designated Data Collection System(s)

20. Confidential and Proprietary Patient Centered Care Questionnaire YesNo 1. Are patients invited to attend your Performance Improvement meetings? 2. Does your facility conduct any form of patient and/or family group meetings? (patient council, support group, new patient orientation group) If Yes, please describe: 3. Do you routinely invite patients/families to your Governing Body meetings? 4. Do you routinely in invite patients/patient’s family to attend their Care Plan meeting? 5. Do you measure the percentage of patients who attend their Care Plan meetings? If Yes, approximately what percentage of the patients attend their Care Plan meeting? 6. Do you have a written policy and procedure related to family participation in the patient’s care such as involvement in the development of the Plan of Care and cannulation?

21. Confidential and Proprietary AIM I Domain: Patient and Family Engagement  Foster patient and family engagement at the facility level  Involve patient/families in CMS meetings  Convene a Patient Engagement Learning and Action Network (LAN) Domain: Patient Experience of Care  Evaluate and Resolve Grievance  Promote use of the ICH CAHPS survey  Address issues identified through data analysis

22. Confidential and Proprietary AIM I Domain: Patient Appropriate Access to In-Center Dialysis Care  Decrease involuntary discharges and involuntary transfers  Address patients at risk for IVD/IVT and failure to place  Generate monthly access to dialysis care reports Domain: Vascular Access Management  Improve AVF rates in prevalent patients  Reduce catheter rates in prevalent patients  Support vascular access reporting  Spread best practices  Provide technical support  Recommend sanctions

23. Confidential and Proprietary AIM I  Domain: Patient Safety : Healthcare - Acquired Infections (HAIs) –Support NHSN –Establish HAI LAN –Reduce Rates of Dialysis Facility Events

24. Confidential and Proprietary AIM II  Population Health Innovation Pilot Project – Decrease Disparities –Increase Vaccinations –Improve Dialysis Care Coordination and Reduce Hospital Utilization –Improve Transplant Coordination –Promote Home Dialysis –Improve Quality of Life

25. Confidential and Proprietary AIM III Domain: Support Data Submission  CROWNWeb, NHSN Domain: Support ESRD QIP  Assist Facilities in Understanding and Complying with QIP Processes and Requirements

26. Confidential and Proprietary AIM I  Foster patient and family engagement at the facility level  Involve patient/families in CMS meetings  Convene a Patient Engagement Learning and Action Network (LAN)  Questionnaire Distributed Today – eventually we will be measuring patient participation  Recruit a few patients willing to attend a meeting with CMS  Recruit patients and develop two campaigns and one QIA

27. Confidential and Proprietary AIM I  Evaluate and Resolve Grievances  Promote use of the ICH CAHPS survey  Address issues identified through data analysis  Everything is now a grievance at the Network level  What are you doing with the aggregate scores?  What are you doing to improve your score each year?

28. Confidential and Proprietary AIM I  Decrease involuntary discharges and involuntary transfers  Address patients at risk for IVD/IVT and failure to place  Generate monthly access to dialysis care reports  Two categories now IVD and IVT  What can we do to identify these patients early on and prevent IVD from the beginning  Report IVD/IVTs to CMS

29. Confidential and Proprietary AIM I  Improve AVF rates in prevalent patients  Reduce catheter rates in prevalent patients  Currently we have no accurate data but we will be targeting the lower performing facilities  Reduce Catheters > 90 days- any facility with >10% may have focused intervention

30. Confidential and Proprietary WITH A CVC! In June 2012, There Were 2,471 Dialysis Patients in New Jersey

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32. AIM I  Support vascular access reporting  Spread best practices  Provide technical support  Recommend sanctions  CROWNWeb  Panel discussions at annual meeting  Go to hospitals with you  Big push by CMS to impose sanctions on recalcitrant facilities

33. Confidential and Proprietary AIM I  Support NHSN  Establish HAI LAN  Reduce Rates of Dialysis Facility Events  NW3 has been working on this for 2 years  HAI LAN established in Puerto Rico in March 2012.  Waiting to hear from CMS what actual indicator will be measured.

34. Confidential and Proprietary USRDS Vascular Access Infection Rates in NJ in 2011 Mean 1.72/100 Pt Months

35. Confidential and Proprietary Vascular Access Infection Rates in NJ 2012 NHSN Self Reported Data on all Patients

36. Confidential and Proprietary AIM II Increase Vaccinations –Patient Hepatitis B –Staff Flu –Patient Pneumonia  Working in Puerto Rico where they have the highest mortality rate related to Flu and Pneumonia in the USA.

37. Confidential and Proprietary AIM III  Reduce costs….  Example: In Puerto Rico in the last 12 months, the BSI was has decreased by 16.4%.  They reduced the use of antibiotics by 20%  Each BSI is estimated to cost about $20,000. So in the 4 th quarter 2011 in PR, 35 facilities had 190 BSIs = $3,800,000. In the 4 th qtr 2012 the same units saved $623,200

38. Confidential and Proprietary Questions? Quality Insights Renal Network 3 109 South Main Street, Suite 21 Cranbury, NJ 08512 609-490-0310

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