Please submit this scan no later than close of business on January 24th, 2020.

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* Select Your Facility from the Dropdown List Provided
(list is sorted by CCN)

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* Name and contact information for person completing this form:

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* Provider Type:
(select best answer)

General Support

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* G1. Are you familiar with Vocational Rehabilitation and/or Employment Network Services and how they can help ESRD patients?

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* G2. Do you currently work with any Vocational Rehabilitation and/or Employment Network Provider in your area?

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* G3. Do you currently educate your patients on VR/EN services available to them for assistance?

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* G4. Do you have a resource for patients listing Vocational Rehabilitation offices and/or Employment Networks in your area?

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* G5. From your experience, what is the biggest barrier for patients regarding Vocational Rehabilitation?

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* G6. Do you have a Policy and Procedure in place that outlines your process in referring patients for Vocational Rehabilitation?

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* G7.  Do you have a Policy and Procedure in place that outlines your process for documenting patients who are referred to Vocational Rehabilitation (VR) or Employment Networks (EN), patients who are actively receiving VR or EN services, patients who have completed VR or EN programs, and patients who are currently employed?

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* G8.  Which of the following would prevent you from referring a patient to VR/EN services?  Choose all that apply

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* G9.  Have you ever had Vocational Rehabilitation/Employment Network Providers come to your facility to speak with patients and/or educate staff?

Data Submission

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* D1.  Do you batch upload vocational rehabilitation or employment status of your patients into CROWNWeb?

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* D2.  How often to you update employment information in CROWNWeb?

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* D3. Who enters data into CROWNweb in your facility?

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* D4.  Is the person who manages CROWNWeb data within your facility familiar with the steps to update a patient’s VR/EN, Employment, and School status?

Patient Partnership and Engagement

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* P1. Does your facility involve patients in the day-to-day culture & education of the facility including to assist in patient education, helping new patients adjust and enjoys being a part of facility activities?

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* P2.  Does your facility have a patient or family member/caregiver that likes to help improve the patient experience of care, through patient education, and/or by welcoming new patients and/or by helping with facility activities?

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* P3.  Does your facility have a patient(s)/family member(s) acting as a Network Patient Representative (NPR)?

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* P4.  Which of the following patient engagement activities do your patients (NPR or other patient/family member representative) participate in currently? (Choose all that apply)

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* P5.  How many care plan meetings did you complete this month? (Enter Numerical Value)

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* P6.  How many patients/family members attended these care plan meetings? (Enter Numerical Value for each response)

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* P7.  What strategies do you currently use to involve patients in the development of their plan of care and/or plan of care meetings? (Mark all that apply)

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* P8.  Does your facility coordinate (or provide information on) established patient support groups OR new patient adjustment groups OR patient councils?

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* If YES to question P8, please indicate all that apply:

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* If your facility hosts a group, how often does the group meet?

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* P9.  Does your facility include patients and/or family/caregivers in the Quality Assurance Performance Improvement (QAPI) Program and/or governing body of the facility?

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* P10) What are the barriers to increase patient engagement at your facility?

Review and Plan

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* Based on the assessment questions above, what would you say is the biggest barrier to increasing utilization of Vocational Rehabilitation and Employment Network Services in your facility?

Based on the assessment questions above, identify two things that your units would like to explore with the Network to increase the utilization of Vocational Rehabilitation and Employment Network Services at your facility.

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* Improvement Opportunity #1:

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* Improvement Opportunity #2:

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