Home: Incident Patients 

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Number of ‘New ESRD’ patients starting dialysis using a home modality. - PD or HHD within the first 90 days. 

Never had incenter modality as their primary modality within a specified time frame. 

Data source -EQRS.

Home: Prevalent Patients

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Number ESRD patients starting on a home modality – PD or HHD after 90 days. 

Data source -EQRS.

Transplant:  Waitlist 

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Number of patients added to the transplant waitlist after completing evaluation at transplant center and found to be good candidates for transplant. Transplant centers have different eligibility criteria. 

Data source- EQRS.

Transplant:  Transplanted 

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Number of Patients who receive kidney transplants in a specified time frame. 

Data source -EQRS.

Vax-Influenza Patient

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Number of patients who have received their annual influenza vaccines.

Facility goals- Increase the percentage of patients receiving influenza vaccination (>90%).

Data source – EQRS.

Vax- Pneumococcal Patients

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Number of eligible patients who have completed their pneumonia vaccination series (fully vaccinated). 

Data source EQRS.

Hosp: Hospital Admissions

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The count of ESRD-related inpatient hospital admissions. 

Data source -EQRS & Medicare Claims.

Hosp: Outpatient ED Visits

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Number of ESRD-related outpatient emergency department visits.

Data source -EQRS & Medicare Claims.

PFE: QAPI

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QAPI- Quality Assessment and Performance Improvement- A goal of patient and family engagement is to create a culture of shared responsibility for improvement within the facility.

Facility Goal- increase the number of patients and family’s participation in QAPI.

Source: Self-reported.

PFE: Life Plan

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A life plan is a roadmap to help patients get the things that mean the most to them and is built around personal goals and dreams. The healthcare team focuses on additional external factors contributing to patients’ outcomes in conjunction with the traditional care plan.

Facility goal- increase the number of patients with documented life plans.

Source: Self-reported.

SPF: Patient Support Program

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Any activity aimed at transferring best practices within the facility (patient to patient engagement ) or outside of the facility (patients engaged in external support group activities). Peer mentorship and Patient Facility Representatives fall in this OKR.  

Facility goal- Increase patient support programs 

Source: Self-reported.

DQ QIA: 2728 Forms within 45 Days

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ESRD Medical Evidence Report Medicare Entitlement And/or Patient Registration Forms- required to add a patient to the ESRD registry and help them apply for Medicare benefits- Due within 45 days of the Admit Date. 

Measure- Percentage of 2728 Forms submitted within 45 days in the last 12 months.

Data source EQRS. 

DQ QIA: 2746 Forms within 14 Days

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Death Notification- required by CMS to be submitted in EQRS within 14 days of the patient's date of death (DOD). 

Measure- Percentage of 2746 Forms submitted within 14 days in the last 12 months.

Data source EQRS.

Depression Screening

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Percent of Medicare patients screened for depression, with results reported in EQRS.

Data source EQRS.