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* 2. Complete the below information.

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* 4. What process does your facility have in place to track and follow up on patient hospitalizations?

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* 5. Do you have access to hospital medical record systems?

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* 6. Do you have a process/policy in place to obtain, review and report Hospitalizations in QAPI?

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* 7. What Network or NCC interventions did the facility implement this month.

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* 8. Provide feedback on at least one intervention you used from the NCC LAN Webinar?

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* 9. How many patients were impacted/educated by one of the NCC LAN intervention this month? Enter a number only.

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* 10. Enter the total number of patient hospitalizations for the reporting month.

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* 11. How many of your patients are currently residing in a nursing facility? (include SNF, Rehab, Short term, and Long term) enter number only

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* 12. Does your facility have at least one Facility Patient Representative (FPR) (may be a patient or family member)?

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* 13. Does your facility have a Facility Support Group(s)?

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* 14. What method(s) are you using to develop support group?

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* 15. What are the barriers in developing and maintaining a patient support group?

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* 16. Did you attend the NCC LAN Webinar/Call this month?

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* 17. Did you utilize any resources provided by the Network or the ESRD National Coordinating Center (NCC)?

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* 18. Do you meet with your patients one-on-one to review their Plan of Care (POC) report?

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* 19. Do you invite your patients to participate in Governing Body Meetings and QAPI Meetings?

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* 20. Does you facility have the Grievance Poster and Patient Engagement Calendar poster displayed for patients to view?

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* 21. Did your facility include patient feedback while completing this survey?

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* 22. Is your facility interested in participating in pilot peer mentoring program “Buddies Wanted”? The Buddies Wanted Program is a mentoring group which utilizes a patient pairing system. New patients will be paired with patients who have been in the facility for at least 6 months and have adjusted to the facility, staff and challenges faced by ESRD patients. Potential participants and candidates will be selected by the facility staff members. Participation in the Buddies Wanted Program is optional.

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