Read the following instructions carefully.

1. Complete the questions below using the Excel tracking tool provided for this project.
2. Complete this survey by the last day of each month.
WARNING: DO NOT USE PATIENT SPECIFIC INFORMATION SUCH AS NAMES, DOB, SOC SECURITY #, ETC. IN THIS SURVEY.
SECURITY VIOLATIONS WILL BE REPORTED TO CMS.

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* 1. Provide first and last name of person completing this survey.

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* 2. Provide email address of person completing this survey.

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* 4. Please check the month you are submitting the home data for (Please select only one each month).

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* 5. How many patients were at your facility for the reporting month?

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* 6. STEP 0 - No action toward Home Dialysis:
Number of patients at the facility not interested, not viable, excluding all acute and transients patients this month.

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* 7. STEP 1 - Patient interest in Home Dialysis:
Number of patients at the facility interested in learning more about Home Dialysis this month.

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* 8. STEP 2 - Educational session on Home Dialysis:
Number of patients at the facility participating in an educational session to determine the patient's preference for home modality this month.

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* 9. STEP 3 - Patient Suitability for Home Dialysis:
Number of patients at the facility suitable for home modality as determined by a nephrologist this month.

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* 10. STEP 4 - Assessment for access placement:
Number of patients at the facility receiving an assessment for appropriate access placement this month.

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* 11. STEP 5 - Placement of access:
Number of patients at the facility receiving placement of an appropriate access this month.

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* 12. STEP 6 - Accepted for Home Dialysis:
Number of patients at the facility accepted for home modality this month.

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* 13. STEP 7 - Begin Home Dialysis:
Number of patients at the facility a beginning home modality this month.

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* 14. Please enter the total number of ACTIVE Facility Patient Representatives (FPRs) or Patient Subject Matter Experts (SMEs) you currently have in your facility? This number may change from month to month. Ideally, facilities should have at least one FPR per shift.

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* 15. Please enter the last time the Home Project was reviewed during QAPI/QA. The expectation is to be addressed once a month and as needed.

Date / Time

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* 16. Please indicate whether a patient or family member attended/participated in the most recent QAPI/QA meeting.

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* 17. Please indicate who from your facility attended the most recent Home NCC Learning and Action Network (LAN) Call. These national calls are scheduled every other month.

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* 18. Has your facility implemented a Patient Engagement (PE) Activity related to Home modalities this month? If "Yes", please select any of the appropriate options AND add a short description in the provided space below. REMINDER: At least one Home PE activity is required during this project.

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* 19. Any barriers or challenges you would like to share around the seven step tracking process this month?

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* 20. Any successes or promising practices you would like to share around the seven step tracking process this month?

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