NW6 - 2019 Home Dialysis QIA: ESRD NCC Home Modality LAN Call Takeaway Survey
3.12.2019 - TRANSITIONAL CARE UNIT - Susan Cooper

Please complete the following information for your facility.

Please answer the following questions to share your takeaway from this NCC LAN call and what you can implement or plan on implementing within the next 30 days at your facility.

INSTRUCTIONS:

This collection tool is DUE APRIL 11th, 2019 by COB.
It will take you approximately 10 minutes to complete.
Survey completion is dependent on all required fields indicated by an asterisk (*).
Click on the "DONE" box at the end of the collection tool to submit your responses to the Network.
Once you have submitted your responses and click on the "DONE" box, you will be directed to the NW6 Home Dialysis QIA webpage.
This collection tool contains hyperlinks for educational resources to share with your patients and family/caregivers.

FACILITY INFORMATION

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* 1. Please select your facility from the drop-down list below; CMS Certification Number (CCN) and Facility Name have been included. PLEASE MAKE SURE YOU ARE SELECTING YOUR FACILITY BY THE "SIX DIGIT CCN" AND NOT BY NAME ONLY, AS SOME FACILITIES HAVE THE SAME OR SIMILAR NAME We want to ensure the correct facility is receiving credit for completion.

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* 2. Enter the contact information of the person completing this form:

First & Last Name *

Discipline or Role

Email Address *

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* 3. Has the Project Lead or Back-up Lead changed since your last survey submission? (Please specify whether the change is for the Project Lead or Back-up Lead)

Yes - Project Lead

Yes - Back-up Lead

If yes, please submit the FIRST & LAST NAME, PHONE, EMAIL ADDRESS of new QIA Lead:
e.g. Michelle Lewis
e.g. 919-463-4510
e.g. mlewis@nw6.esrd.net

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* 4. Has the Patient Health Coach (Staff Role) changed since your last survey submission? (Please provide new contact information)

Yes

If yes, please submit the FIRST & LAST NAME, PHONE, EMAIL ADDRESS of new PHC:
e.g. Michelle Lewis
e.g. 919-463-4510
e.g. mlewis@nw6.esrd.net

Do you oversee other units than the selected facility above for the "HOME DIALYSIS QIA"? If you oversee or are the Project Lead for more than one Home Dialysis QIA participating facility, then you will only need to complete this collection tool once. (Please select up to 4 additional facilities that you oversee and that are currently participating in the Home Dialysis QIA for 2019) **IF NO - PROCEED TO QUESTION 9**

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* 5. Please select the additional facility you oversee for the Home Dialysis QIA from the dropdown box below. (Be sure to select the facility by the CCN and Facility Name, due to facilities having the same or similar names).

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* 6. Please select the additional facility you oversee for the Home Dialysis QIA from the dropdown box below. (Be sure to select the facility by the CCN and Facility Name, due to facilities having the same or similar names).

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* 7. Please select the additional facility you oversee for the Home Dialysis QIA from the dropdown box below. (Be sure to select the facility by the CCN and Facility Name, due to facilities having the same or similar names).

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* 8. Please select the additional facility you oversee for the Home Dialysis QIA from the dropdown box below. (Be sure to select the facility by the CCN and Facility Name, due to facilities having the same or similar names).

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* 9. At the beginning of the Home Dialysis project, you were asked to choose at least one Patient Engagement Activity. Which Patient Engagement Activity have you implemented at your facility? (Please select all that you have implemented up to this point in the project).

Incorporated a patient or family member/caregiver into QAPI

Established a Patient Support Group

Identified a patient to become a Peer Mentor and complete Peer Mentorship Training Program

None

Other (please specify)

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* 10. Please confirm your participation in the CMS established, ESRD NCC hosted Home Modality LAN Call by selecting one of the following options: Home Modality QIA LAN - ESRD NCC

I confirm that I attended the live NCC Home Modality LAN Call offered on March 12, 2019.

I confirm that I have watched the recorded NCC Home Modality LAN Call offered on March 12, 2019 by using the provided link since I did not attend live.

TAKEAWAY QUESTIONS - March LAN Call - Susan Cooper

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* 11. According to the Root Cause Analysis for your facility, what is currently your #1 barrier to increasing home modality utilization?

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* 12. Based on the information shared, which of the following item(s) have you started implementing at your facility or are planning to implement within the next 30 days: Select all that you have or plan to implement.

Patient to patient education about home modality options

Invite a caregiver to share their experience with interested patients and his/her caregiver.

Explore if in-center treatments can be an opportunity to train patients who are interested in home dialysis

Have patients who've had a positive Home Dialysis experience speak to patients who may be interested

Start uremic patients that are in fluid overload on ICH, educate about home options then transition to home training

Place home modality educational resources in the patient waiting area/lobby

Create an Education Station and/or host a Lobby Day

Encourage more family member/caregiver involvement

Discuss home dialysis as a treatment option with all patients

Establish a patient support group

Provide respite care for home patients if needed

If your facility offers a support group, invite a home patient to the support group

Explore chair reassignment to minimize negative influences about home dialysis

Introduce the My Life, My Dialysis Choice decision making tool with patients interested in home dialysis

Hold an in-service for facility staff to learn how to talk to patients about home modality options

None

Other (please specify)

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* 13. How long would you estimate your facility will continue to utilize after implementation the selected response(s) as indicated above?

< 1 month

1-3 months

3-6 months

6-9 months

9 months- 1 year

> 1 year or as long as it is working for my patients

Other (please specify)

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* 14. How many patients do you think you would be impacting by starting to implement the above intervention(s) at your facility: (Enter a whole number e.g. 25)

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* 15. Please indicate what actions your facility will take, that will allow for sustainability of identified intervention(s)/best practice(s) for the period of time indicated: (check all that apply)

Create a huddle board to track the success of intervention(s)/best practice(s)

Report progress to Interdisciplinary Team (IDT)(eg: during Huddles, QAPI meeting, etc)

Create a coalition to discuss successes/barriers of intervention(s)/Best practice(s)

Designate a space in the EMR to document about intervention(s)

Add as a goal in the performance evaluation and keep track of progress

Create a procedure/policy for identified intervention(s) to allow for continued success regardless of staff turnover

Create transparency with patients and family/caregivers by posting progress towards facility goals in patient waiting area (eg: white board in lobby, etc)

Other (please specify)

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* 16. Do any of the following statements reflect the facility/staff views/opinions towards home dialysis utilization for patients at you unit? (Select all that apply)

Patients with right or left-sided weakness are unable to perform home dialysis

Non-adherent patients should not be on a home modality

Morbidly obese patients cannot do home dialysis

Patients with multiple co-morbidities are not good candidates for home dialysis

Only patients with formal modality training are eligible for home dialysis

Patients with mental health diagnosis are not candidates for home dialysis

Homeless patients cannot do home dialysis

A patient must have a partner for home hemodialysis

Advanced age is a barrier to home dialysis

Patients with poor vision cannot be trained for home dialysis

None

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* 17. Have any patients provided feedback (positive or negative) regarding education practices/sessions that they have received about home dialysis options at your facility?

Yes - Please share patient's feedback

FOLLOW-UP QUESTIONS-
February Call (QAPI)

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* 18. You were invited to attend the PFE- NCC LAN Call - Dialysis Patient Engagement in QAPI Process offered on February 12th. Please indicate how this call impacted your practices at your facility if any. (Choose up to 3)

None, I did NOT attend this call

None, I attended but have not implemented the information shared

Collaborate with IDT on how to start incorporating patients in QAPI meetings

Gave me ideas on what I can ask patients to do to improve quality at our facility

Information shared increased my own understanding of QAPI

Changed my perspective of QAPI meeting

We asked patients for topics for the IDT to discuss during QAPI

We spoke to patients and assessed their experience and discussed or plan to discuss results in QAPI

Increased transparency with patients on reporting quality measures in patient areas

Other (please specify)

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* 19. How effective have you found these interventions with your patients or team members?

Extremely effective

Very effective

Somewhat effective

Not so effective

Not at all effective

Other (please specify)

FOLLOW-UP QUESTIONS-
January Call (Home Hemodialysis)

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* 20. Based on the best practices and tips that Dr. Daoui shared during the HOME HEMODIALYSIS NCC LAN Call in January, which of the following item(s) have you implemented at your facility? (Select all that you have implemented up to this point)

Share mortality rate/lifespan when educating patients about home modality

Share with patients that dialysis symptoms may improve when on a home modality

Consider a different approach when educating patients about home treatment options

Address patient or family/caregiver fears about home treatment options

Address patient barriers to home dialysis

Address patient's misconceptions about home dialysis

Ask patients " What's important to them and their lifestyle needs?" before educating

Have a home dialysis patient come to your unit to educate patients about home dialysis

Other (please specify)

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* 21. How effective have you found these interventions with your patients or team members?

Extremely effective

Very effective

Somewhat effective

Not so effective

Not at all effective

Other (please specify)

RESOURCE/TOOL REVIEW

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(MATCH-D) Method to Assess Treatment Choices for Home Dialysis

<p><strong><a href="https://homedialysis.org/documents/pros/MATCH-D-v4.pdf" rel="nofollow" target="_blank">(MATCH-D) Method to Assess Treatment Choices for Home Dialysis </a></strong></p>

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* 22. The Network has shared with you the link to the (MATCH-D) Method to Assess Treatment Choices for Home Dialysis Tool (click on link above). To help us to better serve your needs, please rate the MATCH-D Tool using the 5 Star rating scale:

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* 23. How useful did you find the MATCH-D Tool when educating patients about home dialysis?

Extremely useful

Very useful

Somewhat useful

Not so useful

Not at all useful

Have not used this tool when educating patients

Additional information or concerns utilizing this tool. (please specify)

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Calculate by QxMD (Clinical calculator & decision support tool)

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* 24. The Network has shared with you the link to the Calculate by QxMD Tool (click on link above). To help us to better serve your needs, please rate the Calculate by QxMD Tool using the 5 Star rating scale:

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* 25. How useful did you find the Calculate by QxMD - Clinical calculator & decision support tool?

Extremely useful

Very useful

Somewhat useful

Not so useful

Not at all useful

Have not used this tool

Additional information or concerns utilizing this tool. (please specify)

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* 26. Have you utilized or shared any resources listed on the home dialysis webpage to educate patients up to this point?

Yes

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Home Dialysis Educational Resources

<p><strong><span style="color: #0000ff;"><a href="https://network6.esrd.ipro.org/home/provider/qia/hometherapies/" rel="nofollow" style="color: #0000ff;" target="_blank">Home Dialysis Educational Resources</a></span></strong></p>

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* 27. Please answer the questions below regarding your utilization of the available Home Dialysis resources.

	Yes	No
Have you shared these resources with your IDT?	Have you shared these resources with your IDT? Yes	Have you shared these resources with your IDT? No
Have you shared these resources with patients?	Have you shared these resources with patients? Yes	Have you shared these resources with patients? No
Have you shared these resources with family/caregivers?	Have you shared these resources with family/caregivers? Yes	Have you shared these resources with family/caregivers? No
Have you utilized these resources to refer patients to a home training program?	Have you utilized these resources to refer patients to a home training program? Yes	Have you utilized these resources to refer patients to a home training program? No

QUALITY IMPROVEMENT

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* 28. Do you think the Network's activities and resources have been helpful in supporting your efforts in the Home Dialysis Quality Improvement Activity?

Yes

If No, please explain.

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* 29. Have you identified any new barrier(s) during the month of March related to Home Dialysis utilization at your facility?

Yes, please list identified barrier(s) for the month of March.

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* 30. Have you identified any new success(es) during the month of March related to Home Dialysis utilization at your facility?

Yes, please share your success(es) for the month of March.

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* 31. Have you identified any disparities during the month of March related to home Dialysis utilization at your facility? (e.g. race, gender, demographics, etc.)

Yes - (Please specify your identified disparity during the month of March.

Thank you for completing the March Home Dialysis ESRD NCC LAN Call Takeaway Survey!

We appreciate your time and effort.

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

Quality Improvement Team

IPRO ESRD Network of the South Atlantic

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* 2. Enter the contact information of the person completing this form:

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* 3. Has the Project Lead or Back-up Lead changed since your last survey submission? **(Please specify whether the change is for the Project Lead or Back-up Lead)**

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* 4. Has the Patient Health Coach (Staff Role) changed since your last survey submission? (Please provide new contact information)

Question Title

* 5. Please select the additional facility you oversee for the Home Dialysis QIA from the dropdown box below. (Be sure to select the facility by the CCN and Facility Name, due to facilities having the same or similar names).

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* 6. Please select the additional facility you oversee for the Home Dialysis QIA from the dropdown box below. (Be sure to select the facility by the CCN and Facility Name, due to facilities having the same or similar names).

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* 7. Please select the additional facility you oversee for the Home Dialysis QIA from the dropdown box below. (Be sure to select the facility by the CCN and Facility Name, due to facilities having the same or similar names).

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* 8. Please select the additional facility you oversee for the Home Dialysis QIA from the dropdown box below. (Be sure to select the facility by the CCN and Facility Name, due to facilities having the same or similar names).

Question Title

* 9. At the beginning of the Home Dialysis project, you were asked to choose at least one Patient Engagement Activity. Which Patient Engagement Activity have you implemented at your facility? (Please select all that you have implemented up to this point in the project).

Question Title

* 10. Please confirm your participation in the CMS established, ESRD NCC hosted Home Modality LAN Call by selecting one of the following options: Home Modality QIA LAN - ESRD NCC

Question Title

* 11. According to the Root Cause Analysis for your facility, what is currently your #1 barrier to increasing home modality utilization?

Question Title

* 12. Based on the information shared, which of the following item(s) have you started implementing at your facility or are planning to implement within the next 30 days: Select all that you have or plan to implement.

Question Title

* 13. How long would you estimate your facility will continue to utilize after implementation the selected response(s) as indicated above?

Question Title

* 14. How many patients do you think you would be impacting by starting to implement the above intervention(s) at your facility: (Enter a whole number e.g. 25)

Question Title

* 15. Please indicate what actions your facility will take, that will allow for sustainability of identified intervention(s)/best practice(s) for the period of time indicated: (check all that apply)

Question Title

* 16. Do any of the following statements reflect the facility/staff views/opinions towards home dialysis utilization for patients at you unit? (Select all that apply)

Question Title

* 17. Have any patients provided feedback (positive or negative) regarding education practices/sessions that they have received about home dialysis options at your facility?

Question Title

* 18. You were invited to attend the PFE- NCC LAN Call - Dialysis Patient Engagement in QAPI Process offered on February 12th. Please indicate how this call impacted your practices at your facility if any. (Choose up to 3)

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* 19. How effective have you found these interventions with your patients or team members?

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* 20. Based on the best practices and tips that Dr. Daoui shared during the HOME HEMODIALYSIS NCC LAN Call in January, which of the following item(s) have you implemented at your facility? (Select all that you have implemented up to this point)

Question Title

* 21. How effective have you found these interventions with your patients or team members?

Question Title

(MATCH-D) Method to Assess Treatment Choices for Home Dialysis

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* 22. The Network has shared with you the link to the (MATCH-D) Method to Assess Treatment Choices for Home Dialysis Tool (click on link above). To help us to better serve your needs, please rate the MATCH-D Tool using the 5 Star rating scale:

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* 23. How useful did you find the MATCH-D Tool when educating patients about home dialysis?

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Calculate by QxMD (Clinical calculator & decision support tool)

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* 24. The Network has shared with you the link to the Calculate by QxMD Tool (click on link above). To help us to better serve your needs, please rate the Calculate by QxMD Tool using the 5 Star rating scale:

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* 25. How useful did you find the Calculate by QxMD - Clinical calculator & decision support tool?

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* 26. Have you utilized or shared any resources listed on the home dialysis webpage to educate patients up to this point?

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Home Dialysis Educational Resources

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* 27. Please answer the questions below regarding your utilization of the available Home Dialysis resources.

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* 28. Do you think the Network's activities and resources have been helpful in supporting your efforts in the Home Dialysis Quality Improvement Activity?

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* 29. Have you identified any new barrier(s) during the month of March related to Home Dialysis utilization at your facility?

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* 30. Have you identified any new success(es) during the month of March related to Home Dialysis utilization at your facility?

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* 31. Have you identified any disparities during the month of March related to home Dialysis utilization at your facility? (e.g. race, gender, demographics, etc.)

* 3. Has the Project Lead or Back-up Lead changed since your last survey submission? (Please specify whether the change is for the Project Lead or Back-up Lead)