Working with the ESRD patient

The Network has resources for healthcare providers to assist in clinical practice and to deal with difficult situations. If you are having difficulty placing a patient in an outpatient dialysis facility, your first resource is Medicare's Dialysis Facility Compare to search, and compare dialysis facilities in the United States and Territories. If you are still having issues placing patients in outpatient dialysis facilities, please contact Network Staff to discuss options and potential interventions to overcome barriers to placement.

Resources for difficult situations

If provider staff are dealing with a situation that they feel may warrant a patient's involuntary discharge (IVD) or transfer (IVT), please be aware that the Network and State Department of Health MUST be notified when ANY notice of termination or transfer is given to a patient.

IVD/IVT places patients at extreme risk, and should be considered ONLY as a last resort. IVDs and IVTs are tracked by the Network and reported to CMS monthly. In addition, patients who do not have a Health Care Proxy or Emergency Contact Person are also considered at risk.  In many cases, we have found that early interventions have prevented discharge, and we urge facility staff to identify patients who are at risk early and to contact the Network's Patient Services department for assistance.

IPRO ESRD Network Resources:
Second Chance Trial Program (PDF)

The National Forum of ESRD Networks Resources:
Decreasing Patient Provider Conflict: DPC Toolkit
Dialysis Patient Grievance Toolkit  English  Spanish

Difficult to place patients: 30-day trial period

To address the growing problem of failure to place (F2P) cases, the ESRD Network implemented a program to facilitate placement of these patients. The program was developed in collaboration with CMS and the New York State Department of Health with the following goals:
•To alleviate some of the risk that a dialysis unit assumes when it accepts a known F2P patient
•To ensure that such patients receive the elevated level of support that may be needed to help them adjust positively to the outpatient setting.

Through the program, prospective dialysis units are offered a 30-day trial period during which they may accept a patient for treatment as if he or she is a “transient” patient. The unit accepts the patient with the understanding that there is no commitment to continue treatment after 30 days if the patient causes excessive disruption to the unit or exhibits threatening or violent outbursts. Participating units agree that if the patient refrains from these behaviors, the unit will accept the patient as permanent after the 30th day or the 12th treatment. This gives the unit staff members a chance to get to know the patient and begin to create a specific plan of care that will be implemented if the patient remains at the facility. This also gives the patient the opportunity for stability and continuity of care that is not available in the acute setting. Additionally, the patient gets the opportunity to decide if the particular dialysis unit is the right fit for him or her.

For more information please contact the Patient Services Department.

Treatment Barriers: Definitions

It is important for provider staff and patients to understand patient rights and responsibilities when it comes to access to dialysis. There are many factors that influence a person's choice of dialysis unit: Location, Insurance, chair availability and medical needs to name a few. Below are definitions and a link to the CMS Conditions for Coverage.

It is the medical director’s responsibility to make sure “that no patient is discharged or transferred from the facility unless
1. The patient or payer no longer reimburses the facility for the ordered services;
2. The facility ceases to operate;
3. The transfer is necessary for the patient’s welfare because the facility can no longer meet the patient’s documented
medical needs; or

4. The facility has reassessed the patient and determined that the patient’s behavior is disruptive and abusive to the
extent that the delivery of care to the patient or the ability of the facility to operate effectively is seriously impaired…”
(§494.180 (f) Standard: Involuntary discharge and transfer policies and procedures; Conditions for Coverage for End Stage Renal Disease Facilities)

Prevent treatment barriers before they become an access to care problem. If a patient is at risk of IVD, IVT, or F2P, please contact the Network immediately

Access to care cases include those involving involuntary discharge (IVD), involuntary transfer(IVT), and failure to place (F2P).

Involuntary Discharge

An involuntary discharge is a discharge initiated by the treating dialysis facility without the patient’s agreement.

Involuntary Transfer

An involuntary transfer occurs when the transferring facility temporarily or permanently closes due to a merger, or due to an emergency or disaster situation, or due to other circumstances, and the patient is dissatisfied with the transfer to another facility.

Failure to Place

A failure to place is defined as a situation in which no outpatient dialysis facility can be located that will accept an ESRD patient for routine dialysis treatment.

For more Guidance on Involuntary Transfer/ Discharge and Access to Care, please see our Involuntary Transfer/Discharge webpage.

Patient Services Department:

 Erin Baumann, LMSW
Patient Services Director
   (516) 209-5622