To:
From:
Medical Directors, Facility Administrator/Nurse Managers and Social Workers
Heather Camilleri, CCHT - Quality Improvement Coordinator
Kristin Brickel, RN, MSN, MHA, CNN - Quality Improvement Director
Date:
April 7, 2016
RE:
Population Health Focused Pilot Project (PHFPP): Improve Transplant Coordination
_________________________________________________________________________________
Patients with End Stage Renal Disease have several treatment options including in-center hemodialysis,
home dialysis, or transplantation. Kidney transplantation offers quality of life, improved clinical outcomes
and is a cost effective modality. There are currently 13,931 patients in Network 1, however only 4,159
(29.9%) of these patients are on the kidney transplantation waitlist (as of January 2016) according to the
Organ Procurement and Transplantation Network (OPTN). Transplant coordination is one of many factors
affecting patient’s access to care. We would like to improve the transplant referral process to hopefully
decrease the barriers our community experiences.
IPRO ESRD Network of New England is focusing on improving the quality of life and access to ESRD care through
a Population Health Focused Pilot Project (PHFPP) in the following CMS approved area: Improving Transplant
Coordination. The goal of this project will be to improve transplant coordination, with a focus on a disparate
population. Twelve facilities have been selected to assess and improve the transplant referral process. In order
to establish a baseline for this project, we collected information on patients that were referred to a transplant
center from your facility from April 2015 through January 2016.
For this project a referral is defined as “any first-time referral for a patient (i.e., the patient has not already
been referred or been placed on a transplant waitlist), and for which either a dialysis facility or transplant
center provides an indication that the patient has been referred”. Patients who have had transplant failures
are considered as restarting the referral process anew, and would be eligible for ‘first-time’ referrals.
You are receiving this notice because your facility has been selected to participate in this activity. The
Network’s goal is to increase overall transplant referrals while reducing an identified disparity. The definition of
disparity is ‘lack of similarity or equality; inequality; difference’. The disparity the Network has identified for this
project is race (African American vs. White). Please see the following pages that list both immediate and
ongoing participation requirements for this project.
If you have any questions do not hesitate to reach out to Heather Camilleri, Quality Improvement Coordinator,
at 203-285-1224. We thank you in advance for your participation in this initiative and look forward to working
with you!
Timeline of Activities
February – March 2016
 The Network requested that Facilities provide baseline data for patients who were referred
to transplant for April 2015 through January 2016.
April 2016
 The Network will provide:
o Notification of participation in this activity
o Project overview
o Project agreements for Facility review, signature, and return by April 18, 2016
o Referral collection tool*
*Available facility reports may be submitted if the required data fields are included
o Facilities should submit transplant referrals for February and March*of 2016 by April
14, 2016
*If not already submitted
April – End of September
 Facilities will provide:
o Monthly reporting of patients newly referred for transplant to the Network
(Data Collection Tool is to be faxed no later than the last day of each month)
 The Network will provide:
o Education and resource materials/tools for patients and providers
o Network site visits (May through September)
This project is designed to assist facilities in discussing transplant options with patients, as well as
to provide standardized ways to track referrals both for the facility and the patient. Working
together on this initiative will ideally make the transplant referral process easier for all parties
involved.
Below is the grid of proposed interventions broken out by target of the group for your reference
and review.
Summary of Proposed Intervention Strategies by Target Audience
Intervention Tools and Strategies
Providers
Staff education - brochures, and materials
Patient education - materials, brochures
Technical assistance
Transplantation Resources
Develop Tracking referral form
Development of change concepts
Address barriers
Patient question brochure to ask providers about
transplantation
•
Patients
•
•
•
•
•
•
•
•
•
•
•
Attached to this email is a monthly tracker for transplant referrals to be completed by the last
day of each month and faxed to Heather Camilleri at the Network (203-389-9902). This
document will be used to collect data for ongoing referrals throughout the project period (ending
in September 2016).
This form will include patient level data and must not be sent via email; it must be faxed; if sent
this would be a HIPPA violation.
Note: If your corporation/facility already has a report with the data elements requested you may
submit that to the Network.
For additional information please contact Heather Camilleri at 203-285-1224 or via email
[email protected].
POPULATION HEALTH FOCUSED PILOT PROJECTS (PHFPP) - PROJECT AGREEMENT
Dear Provider,
The Network shall achieve Centers for Medicare and Medicaid Services (CMS) goals through the
development and implementation of quality improvement activities, such as the activity noted below.
As directed by the Network governing bodies, 2016 performance goals have been set that every
dialysis facility is expected to achieve.
Please carefully review the notification letter and attached objectives for the Population Health
Focused Pilot Projects (PHFPP) – Improve Transplant Coordination. After review, please complete the
necessary fields, have the Project Lead, Facility Administrator/Nurse manager, and the Medical
Director sign, and return to the Network office via email at [email protected] or by fax at (203)
389-9902 by April 18, 2016.
**Please note, regardless of assigned Project Lead, Medical Director and Facility
Administrator/Nurse Manager are responsible for ensuring completion of project objectives.
In anticipation to your timely response, I thank you for your ongoing support and cooperation with the
Network. If you have any questions or additional information is needed regarding these goals, please
contact Quality Improvement Department at [email protected].
Sincerely,
Danielle R. Daley, MBA
Executive Director
Heather Camilleri, CCHT
Quality Improvement Coordinator
CC: MEDICAL DIRECTOR, FACILITY ADMINISTRATOR/NURSE MANAGER, REGIONAL CONTACT
PHFPP QIA: IMPROVE TRANSPLANT COORDINATION - PROJECT AGREEMENT
APRIL 2016 – OCTOBER 2016
The undersigned hereby agrees to participate and cooperate with the goals and activities, including quality
improvement projects, as set forth by IPRO ESRD Network (42 CFR Part 494.180.V772 (i) of Centers for Medicare
& Medicaid Services (CMS) regulations).
Facility Name (DBA):
Medicare Provider # (CCN):
Project Lead Name:
Project Lead Title: ___________________
Project Lead Signature: ____________________________________
Date:
Project Lead Email: _________________________________________________________________
Medical Director:
Medical Director’s Signature:
Date:
Medical Director Email: _________________________________________________________________
Facility Administrator/Nurse Manager Name: ________________________________________________
Facility Administrator/Nurse Manager Signature: _____________________________________________
Regional Director/Area Administrator:
Phone: __________________
Regional Director/Area Administrator Email: ________________________________________________
Any changes to the above listed contacts must be reported to the Network and corrected in CROWNWeb
within 5 business days to ensure continuity with project implementation and communications between the
Network and Facility. Plans are reviewed periodically, and are subject to change based on the CMS Statement
of Work (SOW).
QUALITY IMPROVEMENT ACTIVITY
 PROJECT OBJECTIVE: Increase overall transplant referrals while decreasing the disparity
o PRIMARY PROJECT MEASURES
1. Monthly Transplant Referral Data Collection Tool
o PRIMARY PROJECT GOALS
1. Increase overall transplant referrals by 5%
2. Decreasing the disparity gap by 1%
 ACTION ITEMS / FACILTY REQUIREMENTS
o Report, via fax, new referrals through end of September 2016
o Educate patients and staff using transplant resources
Transplant Referral Data Collection Tool
Reporting Month:
Click here to enter text.
Deadline Date:
The last day of each month
Attention:
Heather Camilleri, CCHT
Fax Number:
203-389-9902
From:
Click here to enter text.
Provider Name:
Click here to enter text.
Medicare/CCN:
Click here to enter text.
Patient Name
Referral
Date
Patient DOB Patient Race
Patient
Ethnicity
Patient
Gender
Transplant Center
Jane Doe (Example)
4/5/2016
6/1/1959
Hispanic
☒ Female
ABC Dialysis
DO NOT send any patient
information (PHI or PII) to the
Network via e-mail.
This form contains multiple fields of
patient-level data, it is very
important to send to the Network
via FAX ONLY. It will be reported as
a security violation if sent via e-mail.
White
☐ Male
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Click here to enter text.
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Click here to enter text.
Click here to enter text.
Click here
to enter a
date.
Click here to Choose an item.
enter a
date.
Choose an
item.
☐ Female
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to enter a
date.
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enter a
date.
Choose an
item.
☐ Female
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to enter a
date.
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enter a
date.
Choose an
item.
☐ Female
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to enter a
date.
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enter a
date.
Choose an
item.
☐ Female
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to enter a
Click here to Choose an item.
enter a
Choose an
item.
☐ Female
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☐ Male
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☐ Male
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☐ Male
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☐ Male
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Patient Name
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Click here to enter text.
Total Patients
Referred for the Month
Referral
Date
Patient DOB Patient Race
date.
date.
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to enter a
date.
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enter a
date.
Choose an
item.
☐ Female
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to enter a
date.
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enter a
date.
Choose an
item.
☐ Female
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to enter a
date.
Click here to Choose an item.
enter a
date.
Choose an
item.
☐ Female
Click here
to enter a
date.
Click here to Choose an item.
enter a
date.
Choose an
item.
☐ Female
Click here
to enter
text.
Patient
Ethnicity
Patient
Gender
Transplant Center
☐ Male
Click here to enter text.
☐ Male
Click here to enter text.
☐ Male
Click here to enter text.
☐ Male
Click here to enter text.
☐ Male
This form contains multiple fields of patient-level data, it is very important to send to
the Network via FAX ONLY. It will be reported as a security violation if sent via e-mail.