Please complete the following information for your facility.

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* 1. Please select your facility from the dropdown list below; facility name and CMS Certification Number (CCN) have been included.

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* 2. Total In Center HD Patient Census

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* 3. Has the project lead for this QIA changed since last submission?

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* 4. Name of person completing this form:

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* 5. E-mail address:

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* 6. How is your process for educating patients on their treatment options sustainable?

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* 7. Please list any successes or barriers to patients advancing through the steps in the month.

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* 8. Does your facility have an Education Station/Bulletin Board?

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* 9. Please rate the Tools that we featured in May

  Poor Below Average Average Above Average Excellent
Match D Staff tool for Identifying Home Therapy Candidates
My Life, My Dialysis Choice Website Tool for patients, family members, care partners

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* 10. Would you like the Network to USPS mail Home Therapies Educational Materials to your facility?

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* 11. Comments and or Suggestions for Improvement

Instructions for Entering Monthly Step Data: (Required for Independent Facilities) Optional for facilities using LDO Batching (DCI, DaVita and FMC)
Monthly Data: Please include the total number of patients who during the month have entered the step for the first time or have not progressed to the next step.  (Each patient should only be counted in ONE Step)
Note: Not all patients will begin at step 1.  If a patient has attained more than one step in a month, only count them in the highest numbered step attained. i.e. Patient expressed interest and attends education session in the month would be counted in step 2

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* 12. Step 1: Number of Patient(s) interested in home dialysis

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* 13. Step 2: Number of Patient(s) Attending Educational session to determine patient preference.

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* 14. Step 3: Number of Patient(s) suitable for home modality as determined by a nephrologist with expertise in home dialysis therapy

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* 15. Step 4: Assessment for appropriate HT access placement

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* 16. Step 5: Placement of HT Access

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* 17. Step 6: Patient Accepted for HT Training

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* 18. Step 7: Patients Training for Home Therapies

Thank you for completing this form. 
We appreciate your time and effort.

Please click on "DONE" to submit your responses to the Network.

Quality Improvement Team
IPRO ESRD Network of New York

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