Forum of ESRD Networks

Introduction

The ESRD Program was established into United States (US) law in 1972 to provide Medicare coverage for patients who require maintenance dialysis or kidney transplantation to survive. The ESRD Networks Organizations were congressionally mandated to deliver quality oversight services to chronic dialysis facilities under contract to the Centers for Medicare & Medicaid Services (CMS) in 1978.^1–3 Currently, 18 geographically distinct ESRD Network Organizations (Figure 1) provide CMS-aligned quality oversight and technical assistance to ESKD providers including dialysis clinics, transplant centers, and patients.

Figure 1.

18 ESRD Networks, CMS ESRD contracted Organizations, and the Organizational Chart of the Forum of ESRD Networks. Geographic distribution of the 18 congressionally mandated ESRD networks and the CMS contracted “QIN-QIO” to manage ESRD networks for the contemporary contract period from 2021 to 2026 (A). Additional CMS contracted entities that work closely with ESRD networks are listed in the upper right corner (B) including the EQRS (formerly known as CROWNWeb), ESRD, the KCER, and TAQIL. The organization chart of the National Forum of ESRD Networks is depicted in the lower right corner (C). CMS, Centers for Medicare & Medicaid Services; CROWNWeb, Consolidated Renal Operations in a Web-enabled Network Web; EQRS, ESRD Quality Reporting System; KCER, Kidney Community Emergency Response; NCC, National Coordinating Center; QIN-QIO, Quality Innovation Network–Quality Improvement Organizations; TAQIL, Technical Assistance, Quality Improvement and Learning.

The Networks focus on ESKD educational and data support using the national ESRD Quality Reporting System data (formerly known as Consolidated Renal Operations in a Web-enabled Network Web) and work closely with the Kidney Community Emergency Response overseeing ESKD disaster management. Every 5 years, CMS invites Quality Innovation Network–Quality Improvement Organizations to apply competitively for contracting 18 ESRD networks and Kidney Community Emergency Response. Figure 1 shows current Quality Innovation Network–Quality Improvement Organizations contracts from 2021 to 2026.

CMS sets the Networks' contract priorities through the Statement of Work, which are not specifically aligned with the Quality Incentive Program (QIP) or 5-Star Ratings. Networks assist providers during the QIP review period to ensure accuracy and address issues in reporting. Facilities needing assistance with QIP measures or low 5-Star Ratings may reach out to their Network to ask for guidance on improving quality measures. One such example of Network outreach would include efforts to assist dialysis providers with the implementation of the revised 2728 Medicare entitlement form, Networks distributed tools, tip sheets, and educational opportunities to ensure accurate and timely submissions.

The Forum and Its Mission to Improve the US ESRD Program

All 18 ESRD Networks are members of the National Forum of ESRD Networks and represented through a committee structure outlined below. The Forum is a registered 501(c)(3) not-for-profit organization sustained by membership dues and generous community donations with a purpose of facilitating the flow of information and advancing a national quality agenda with CMS and other partners and stakeholders. The mission of the Forum is to support and advocate on behalf of the Networks in promoting methods to improve the safety and quality of care to patients with kidney disease. The Forum designs current and future priorities to support the Networks in achieving national quality improvement goals and statutory requirements, as outlined in Section 1881 of the Social Security Act and the Omnibus Budget Reconciliation Act of 1986. The Forum partners in the quality improvement processes by creating collaborative relationships with the entire kidney community. They develop and disseminate education and innovative intervention resources that are in alignment with the Network's CMS Statement of Work with an overarching goal of improving the standard of care for patients.

The Forum's priority aim is to develop a framework for strategic alliance building to partner with stakeholders, particularly CMS and its Division of Kidney Health, Quality Measurement and Value-Based Incentives Group, and the CMS Innovation Center. Through regularly scheduled meetings with Division of Kidney Health leadership, Forum's affiliates have had the opportunity to discuss issues of national concern such as the care of ESKD patients during the coronavirus disease 2019 pandemic (e.g., timely access to vaccines, personal protective equipment, and staffing adequacy) as well as reviewing lessons learned from disaster management response efforts. Recent efforts have evaluated reasons behind dialysis unit closure trends.⁴ The Forum also has a long-standing history of gathering the perspective and expertise of its members and partners to submit timely reviews of CMS ESRD proposed rules, value-based care models, and ESRD measures.

Forum Structure and Focus on Patient-Centeredness

The Forum is composed of the Executive Director Advisory Council, which includes each Network's Executive Director, and the Medical Advisory Council (MAC), featuring representatives from each Network's Medical Advisory Boards. To further enhance the Forum's impact and relevance, the Board of Directors formed a third council in 2012, the “Kidney Patient Advisory Council” (KPAC). Like Executive Director Advisory Council and MAC, KPAC members represent their Networks, with its cochairs serving as voting members on the Forum's Board of Directors.

The KPAC plays a crucial role in representing the voices of people with kidney disease. It ensures that their perspective influences the Forum's quality improvement projects while serving as a bridge between patients and healthcare providers through sharing of real-life experiences. The KPAC has more recently focused on advocacy for ensuring patient access to dialysis modality options (e.g., patient education and assisted home support), improved mental health care and financial services, and efforts that maintain the central focus on quality of life and living well with kidney disease.

Forum Toolkits

A key accomplishment of the Forum is the creation of patient and provider education through online toolkits (https://esrdnetworks.org/toolkits). KPAC-specific toolkits (intended for patients) include “Is a Kidney Transplant Right for Me?,” the Financial Health Resources Toolkit, the Dialysis Patient Depression Toolkit, and the Dialysis Patient Grievance Toolkit.

Professional toolkits developed by the MAC (intended for nephrologists and all dialysis team members) are created through a collaborative effort of multiple experts with the intent of offering evidence-based education. The Outpatient Dialysis Medical Director Toolkit offers a comprehensive overview of the scope of responsibility defined in the ESRD Conditions for Coverage. It includes chapters on dialysis water treatment, patient-provider conflict, quality assessment and performance improvement, regulatory surveys, and physician leadership. In 2020, the Forum released the Inpatient Dialysis Medical Director Toolkit, the first of its kind to address the nuanced regulatory aspects and clinical responsibilities of the inpatient physician director.⁵

With home dialysis therapy being one of the pillars of kidney patient care (yet also recognized as an area consistently lacking in quality training) the Forum's Home Dialysis Toolkit provides home therapy–specific education regarding Conditions for Coverage updates, emergency management, and enhanced modality education including transitional care and self-care, while also covering value-based care insights and home dialysis challenges from the patient perspective.

The Vaccination Toolkit offers a comprehensive summary of the vaccination schedules that includes user-friendly worksheets for facility documentation.⁶ The Health Equity Toolkit has been developed to promote quality healthcare within the kidney community, with a special focus on the social drivers of health, patient engagement and health literacy, care for the immigrant ESKD population, and approaches to address patient-provider disagreement.^7,8

Future Strategic Priorities

Moving forward, the Forum looks to extend its strategic partnerships with groups such as the American Society of Nephrology (regulatory-focused education) and the Veteran's Administration (streamlining ESKD care with those outside the Network framework). Improving customer outreach and information sharing through Forum-led education remains another priority. High-level toolkit reviews (as outlined above) will be shared broadly through online lectures beginning in 2025. The Forum also uses a peer-reviewed online platform of Sharing Highly Effective Practices to highlight such successful Network projects as the “Second Chance Program” reducing involuntary discharges and a patient-centered emergency management portal.

Conclusions

The 18 ESRD Networks under the CMS contract serve as liaisons between the Government and ESKD providers. The Forum advocates on behalf of the Networks, coordinates projects, and facilitates the flow of information as it advances a national quality agenda with CMS, kidney organizations, and the nephrology community. Recent areas of focus included the creation of free on-line toolkits for provider education, sharing highly effective practices throughout the United States, and helping elevate the voice of the kidney patient community.

Supplementary Material

cjasn-20-1286-s001.pdf ^{(1.4MB, pdf)}

Disclosures

Disclosure forms, as provided by each author, are available with the online version of the article at http://links.lww.com/CJN/C297.

Funding

None.

Author Contributions

Resources: David Henner, Kamyar Kalantar-Zadeh.

Supervision: David Henner.

Writing – original draft: Mary Albin, Mary Baliker, Dawn P. Edwards, David Henner, Andrew Howard, Kamyar Kalantar-Zadeh, Daniel Landry, Dee LeDuc, Donald A. Molony, Ramin Sam, Preethi Yerram.

Writing – review & editing: Mary Albin, Mary Baliker, Dawn P. Edwards, David Henner, Andrew Howard, Kamyar Kalantar-Zadeh, Daniel Landry, Dee LeDuc, Donald A. Molony, Ramin Sam, Preethi Yerram.