Form Due by February 10, 2020

Please submit only one report per facility.  Data on your submission should reflect what happened in the month of January 2020.

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* Select your facility from the drop down list.
(list is sorted by CCN = CMS Certification Number)

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* Enter your name and phone number.

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* 1. Throughout January, how many patients were educated on Vocational Rehabilitation (VR) and/or Employment Networks (EN)?
(enter whole numbers only)

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* 2. What type of patient education (about Vocational Rehabilitation / Employment Networks) was performed during the reporting month?
(select all that apply)

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* [OPTIONAL]
Do you have a picture you would like to share to highlight what you have done this month?

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 3. How many VR eligible patients do you currently have in your facility in the reporting month?
(enter numerical value)
-- Eligibility Criteria for VR:  (1) Between 18 through 54 years of age; (2) Blind or have a disability AND receive SSDI or SSI benefits; (3) not currently employed, in school, or receiving specialized training

0 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 4. How many patients between 18 and 54 years of age in your facility are currently employed?

0 50
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 5. How many patients between 18 and 54 years of age in your facility are currently enrolled in school?

0 50
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 6. How many patients, if any, have you referred to VR or EN services in the reporting month?

0 10
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 7. How many patients, if any, had their first appointment with VR/EN during the reporting month?

0 10
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 8. [Did you know patients aged 55 through 64 are eligible for Employment Network Services?  Tracking EN-specific referrals for this age range cannot be submitted through CROWNWeb at this time.]
How many patients between 55 and 64 years of age (on the date of referral) did you refer for Employment Network (or Vocational Rehabilitation) services this month?
(enter numerical value)

0 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 9. How many patients between 55 and 64 years of age were using Employment Network (or Vocational Rehabilitation) services this month?
(enter numerical value)

0 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 10. Did your dialysis facility staff receive any new education or participate in a Team Meeting on Vocational Rehabilitation and/or Employment Network Services?

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* 11. Does your facility have a Promising Approach or Best Practice regarding staff or patient communications, training, procedures, or engagement that you would be willing to share with the Network?

Patient and Family Engagement Assessment
PFE Goal 1: Network Patient Representative in each dialysis facility in the Network region

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* P1. This month, my facility ...
(select all that apply)

PFE Goal 2: Increase patient/family involvement in the development of their plan of care and/or plan of care meeting

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* P2.  My facility took the following actions to impact this goal during the reporting month:

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* P3.  How many care plan meetings did your facility complete this month?

0 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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* When answering the following questions, consider the number of patients/family members who attended the care plan meetings from the number you indicated in the question above.

[enter numbers only]

PFE Goal 3: Facilities will establish patient support groups; new patient adjustment groups and/or patient councils

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* P4. Does your facility coordinate (or provide information on) established patient support groups OR new patient adjustment groups OR patient councils?

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* P5.  My facility took the following actions to impact this goal during the reporting month:

PFE Goal 4: Facilities will include patients and/or family members/caregivers in the Quality Assurance Performance Improvement (QAPI) Program and/or governing body 

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* P6. Does your facility include patients and/or family members/caregivers in the Quality Assurance Performance Improvement (QAPI) Program and/or governing body of the facility?

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* P7.  My facility took the following actions to impact this goal during the reporting month:

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* P8.  What other resources would be helpful for you to meet the PFE Goals?
(please include your name and email address so we can follow up with you)

Resource / Activity Review -- For January Reporting

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* R1.  Did you, or someone from your facility staff, attend the 2020 Network Council Kick-Off Webinar?
(The webinar was hosted by Network 12 on January 8.  Here is a link to the recording:  https://attendee.gotowebinar.com/recording/759676077477220610)

Monthly Wrap Up

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* What support do you need from your ESRD Network to help with the Vocational Rehabilitation QIA initiative? (please include your name and email address so we can follow up with you)

T