All Physicians’ Forms

Please ensure that your patients are aware that you will send their personal health information to another organization (Northwest Kidney Centers). This will allow us to prepare records and offer information, counseling, and education services.

Chronic Kidney Disease (CKD) Education

We encourage nephrologists to refer CKD patients not yet on dialysis for Choices modality education as well as nutrition education. Classes are offered several times each month at multiple locations as well virtually.  Additionally, individual sessions are available for patients who require interpretation or may not be classroom appropriate (e.g. mental health, special needs). Refer by completing the Referral for CKD Services form at https://www.nwkidney.org/for- physicians-staff/all-physicians- forms and uploading supporting records to the online portal, or phone the CKD Program at (206) 292-2771, ext. 1082.

For CKD patients who have already attended Choice’s modality education, Nephrologists can refer patients for additional education on home hemodialysis, peritoneal dialysis, and transplant via the Next Step classes by contacting the CKD Program at 206-292-2771 ext. 1082.

New Patient Referral

Northwest Kidney Centers Active and Courtesy medical staff may refer patients in need of dialysis to Northwest Kidney Centers by accessing the Northwest Kidney Centers website and completing the Dialysis Patient Referral Form at https://referrals.nwkidney.org/.  This portal will walk you through the items we need to collect to initiate and finalize a referral.  This includes:

• Dialysis Patient Referral form
• History & Physical, Discharge Summary or Renal Progress Notes within 45 days
• HbsAg, total anti-HBc and anti-HBs drawn within 30 days
• Evidence of screening for tuberculosis (2 step TST, interferon gamma release assay (IGRA) or chest xray)
• Initial Physician’s Orders signed by the primary Nephrologist caring for the

Completing the Referral Form

Complete responses on the referral form are essential to accurately fulfill CMS’s reporting mandate. Your signature on the referral form serves as your endorsement of initiation of Northwest Kidney Centers’ standing orders for your patient.

History and Physical

To assure appropriate care and patient safety, the Conditions for Coverage require a pre- initiation nursing review of a new patient’s clinical history (V715). The nurse must determine whether any critical clinical issues exist which might make initiation of dialysis problematic. We need at least one of the following completed within 45 days of start of dialysis:

• A Medical history and physical examination; or
• A discharge summary from a recent admission which includes a problem list; or
• Detailed nephrology progress notes with a problem list

Hepatitis B

Hepatitis B surface antigen results are required for admission to Northwest Kidney Centers and should be no more than 30 days old. Please note these results on your referral form and provide the hard copy as well.

Hepatitis B surface and core Ab is now required and will be collected at the time of a patient’s arrival if not provided as part of the referral (V124).

Transfer In

Transfer-In patients are accepted upon referral by a member of the Northwest Kidney Centers Active or Courtesy Medical staff using the Northwest Kidney Centers Referral Form. Records are also required from the sending facility.

All standing orders, including “Chronic Maintenance In-center Hemodialysis Standing Orders,” Peritoneal and Home Hemodialysis standing orders and new patient “Initial Orders” area available on the Knet under “Clinical” and on the NKC website www.nwkidney.org under “For Physicians and Staff” – “For Nephrologists” – “Physicians’ Forms.”

Orders requiring CMO or facility Medical Director Signoff

• Nonstandard bath
• DFO (deferoxamine, Desferal)
• Any off-menu dialyzer

Dialysis Orders Post Hospital Discharge

Verify dialysis orders with Northwest Kidney Centers facility the patient is going to post discharge (including dialysis prescription, bath, dry weight, etc.)

Verification of Orders for Medical Staff in the EMR:

All orders must be authenticated by the attending nephrologist of record within 30 days. Authentication means that you have seen the order. If you do not agree with the order, you still need to verify that you have seen it. You should then call, fax or send a new order. You can write the order as the physician or call the Unit directly with the order. Once the order is in the EMR, Northwest Kidney Centers staff will carry out the order as directed. Orders can be completed before they are verified.

The attending nephrologist is responsible for verifying orders in the EMR placed by covering nephrologists, whether active or courtesy staff.

Delinquency in Verifying Orders

To be in compliance with Medicare regulations, nephrologists with unverified orders >30 days may be contacted by the office of the Chief Medical Officer to request authentication.  If orders remain unverified, nephrologists may have privileges for verbal order submission suspended until they are in compliance. A letter will be placed in the medical staff file that privileges for verbal orders have been suspended until the physician has verified their orders and is in compliance with Northwest Kidney Centers policy.

Nephrologists with unverified orders >60 days, after having been given a warning notice and written letter of suspension of verbal orders, may be notified that Medical Staff privileges have been suspended until they are in compliance, and a letter will be placed in the credentialing file.

Dialysis > 3 Times Per Week

It is critical that every month you examine your patient lists for those who you have ordered more than thrice-weekly treatments and ascertain that their rationales for the extra treatment are both current and correct. Please be as specific as possible with the rationale you note. Volume rationales are intuitive and self-evident. Other metabolic problems such as unmanageable electrolyte issues, pericarditis, oxalosis, etc. should be indicated explicitly.

If the patient requires an extra treatment during the month for patient or procedure- related matters (i.e., frequent treatment interruptions due to bathroom breaks, poor catheter function, machine malfunction, etc.) the reason for the inadequate dialysis should be noted and an ICD-10 code provided. It does not appear that neuropathy will be an acceptable rationale for more than three treatments per week and may require an appeal and additional justification. Even then, there is no guarantee that it will be accepted.

Issues related to inadequate delivery of dialysis dose should be indicated as “inadequate” dialysis. All your rationales for more than three treatments should be incorporated into the electronic medical record.

DNR Policy

Northwest Kidney Centers supports the belief that the patient is the primary decision- maker for their personal health care. Unless otherwise specified, the default code status for every patient at Northwest Kidney Centers will be Full Code, meaning that all appropriate resuscitative measures will be undertaken in the event of a respiratory or cardiac arrest. A Do Not Resuscitate (DNR) order written by a physician indicates that a patient and/or legally authorized person acting in the patient’s best interest and physician have agreed that no resuscitative measures will be taken in the event of a respiratory or cardiac arrest. The physician order is sufficient.

However, best practice includes attaching an advance directive, and preferably a Physician Orders for Life- Sustaining Treatment (POLST form). Verbal DNR orders will not be accepted. Special care units require that the patient’s code status be reviewed and updated before admission.

Death With Dignity Act

Northwest Kidney Centers will not provide life-ending medication based on the November 2008 “Death With Dignity Act.” In keeping with our mission and values, Northwest Kidney Centers physicians, employees, independent contractors and volunteers, including our hospital services staff and pharmacy staff, will not assist a patient by providing life-ending medication on our premises or while acting on behalf of Northwest Kidney Centers.

Our current laboratory partner is Neway Labs, which provides the IT infrastructure and reporting tool for labs performed by Quest Diagnostics for the dialysis industry.  Lab results performed through Neway labs and Quest Diagnostics are available through the NKC electronic health record (Clarity). 

Critical Lab Definition

Critical lab values are defined as values that are outside the normal range to a degree that may constitute an immediate health risk to the individual or require immediate action on the part of the ordering physician.  CLIA §493.1291(g) regulation requires laboratories to “immediately alert the individual or entity requesting the test and, if applicable, the individual responsible for using the test results when any test result indicates an imminently life- threatening condition, or panic or alert values.”

Critical Results Notification

• During daytime business hours, critical lab results will be called directly to the charge nurse at the NKC dialysis clinic where the patient is dialyzing. NKC staff are responsible for alerting the ordering provider or the coverage immediately regarding the critical results
• After business hours, critical labs will be faxed to the clinic and will also be delivered the next morning by phone. NKC staff are responsible for alerting the ordering provider or their coverage immediately regarding the critical results

Panic Definition

Panic values include test results considered life-threatening and may require immediate intervention by the healthcare provider. CLIA §493.1291(g) regulation requires laboratories to “immediately alert the individual or entity requesting the test and, if applicable, the individual responsible for using the test results when any test result indicates an imminently life- threatening condition, or panic or alert values.”

Physicians are required to provide a diagnosis with an ICD-10 code when ordering an antibiotic or other medication to be administered intravenously on dialysis (except routine medications such as Mircera, Ferrlecit and Doxercalciferol).

Deferoxamine (DFO)

The CMO will review orders for DFO in discussion with the primary physician, so that therapies can be individualized. This policy stems from the infrequency of these orders, the potential for other clinical strategies which accomplish similar results, and the small, but finite risks of repetitive administration, particularly large doses.

Levocarnitine

Previously it was felt that there were indications for L-carnitine supplementation. Several consensus conferences as well as the NKF-K/DOQI groups concluded that routine carnitine supplementation in dialysis patients is NOT justified by available data.  Evidence is not strong enoughtoendorsetheuseofL-carnitineforanyoftheindicationsforwhichithasbeenrecommended.

Difelikefalin (Korsuva)

Difelikefalin requires CMO approval. Itch intensity must be assed and documented on two different occasions more than 24 hours apart prior to starting Difelikefalin. Itch improvement must be documented one month after starting Difelikefalin for continued use to be considered. Fax the Pruritis Assessment – Difelikefalin Request to Pharmacy at 206-343.4884.

Etelcalcitide (Parsabiy)

Etelcalcitide requires CMO approval. Before requesting etelcalcitide, the patient should have demonstrated cinacalcet treatment failure. as indicated by persistently elevated PTH levels despite receiving the maximum tolerated dosage of cinacalcet.

Sodium Thiosulfate (STS)

Sodium thiosulfate requires CMO approval. Conclusive evidence supporting the use of sodium thiosulfate for the treatment of calcific uremic arteriolopathy is lacking.  However, giving the severity of the condition, and the lack of viable alternatives, sodium thiosulfate may be requested. Doses are limited to 12.5 grams three times per week for patients weighing less than 70 kilograms, and 25 grams three times per week for patients weighing more than 70 kilograms. Sodium thiosulfate orders are limited to three months duration. Order continuation beyond the initial 3-month authorization must be approved by the CMO.

Fax the Sodium thiosulfate (STS) Order Form to Pharmacy at 206-343-4884.

When seeing patients in the dialysis facility, please be aware of areas which are considered microbiologically clean or dirty, the need for hand hygiene when entering and exiting the clinical areas of the facility and for appropriate lab coat or gown coverage when interacting with the patient if potential blood or body fluid exposure is possible.

Difficile

The special Care Units have private treatment rooms with their own bathroom so that C. diff patients can be treated until they are no longer having active diarrhea.

Hepatitis B Positive Patients

Dialysis for HbsAg-positive patients will be provided in-center or at the patient’s home. Several centers have hepatitis B isolation roomsavailable. Staff will not care for antigen-positive and antigen-negative patients in the same shift unless the antigen negative patients have immunity as evidenced by a positive surface antibody.  The ESRD Conditions for Coverage require us to obtain hepatitis B core antibody (anti-HBc) as one of the routine hepatitis serologies before a patient starts care in a dialysis facility.

Multi-drug resistant organisms (MDROs)

Patients infected or colonized with certain multi-resistant microorganisms such as C. Auris or carbapenem-resistant enterobacteraceia (CREs) require contact precautions during dialysis.  Decisions regarding discontinuation of infection precautions will be made based on contain ability of potential sources of organisms, the hygiene of the patient, and whether the patient can comply with a simple wound-care regimen.

QA/PI (Quality Assessment/Performance Improvement)

A critical component of patient care oversight is facility-wide quality assessment and performance improvement (QA/PI). QA/PI is separate from the individual medical staff member’s responsibility under the Conditions for Coverage, which centers on completing individual patient assessments and plans of care, meeting treatment goals and more extensive attention to unstable patients. QA/PI, in contrast, is a process supervised by the facility’s medical director and interdisciplinary team to evaluate and improve overall facility performance and quality of care. Data on current professionally-accepted clinical practice

standards must be used to track health outcomes, and the program must allow for identification, prevention and reduction of medical errors, mortality, and morbidities. Refer to the Measures Assessment Tool (MAT) which lists expected outcomes based on these standards and CMS Clinical Performance Measures (CPMs).

Although the medical director and the interdisciplinary team execute the QA/PI program, you are involved through the daily care of your patient. From this standpoint, you participate in efforts to improve the quality of medical care to your patients. These efforts must be reflected both in documentation of the QA/PI program and in the medical records of individual patients. Examples include the development of the patient’s plan of care and addressing poor patient outcomes with a change in the plan of care. Evidence of understanding and agreement of your responsibilities relating to QA/PI may be documented in your credential files

Face-to-Face Encounters and Office Visits

A significant component of the Conditions for Coverage is documentation of face-to- face visits with your patients. The patient’s physician, practice partner, ARNP or PA must see the patient at least once a month at the office or dialysis facility. They then must document that encounter (or specify the reason the visit did not occur) for both in- center and home dialysis patients. Any of these practitioners (MD, ARNP or PA) must also see and document having seen in-center hemodialysis patients during dialysis at the facility once quarterly. Visits, whether in office or unit, are to be documented in an area of in the EMR designed for this purpose.  Please “cc” your dictated office visits, discharge summaries and medical correspondence to Northwest Kidney Centers Medical Records, 12901 20th Ave S, SeaTac, WA 98168, or via fax: 206- 901-8725 rather than directly to the unit, and they will be scanned into the EMR Unit staff can print it from the EMR.

Comprehensive Assessment and Plan of Care

The Conditions for Coverage delegate the mechanics of care planning entirely to the patient’s MD as the leader of an interdisciplinary care planning team. This team is composed of the patient’s MD, the social worker, renal dietitian, clinical director, case manager, and patient, who are together responsible for determining the direction of care planning and generating relevant documents which chart its forward course. This responsibility includes generating initial assessments at 30 and 120 days for new patients (called the Comprehensive Assessment), assessing stability (obligating yearly comprehensive assessment) or instability (obligating monthly comprehensive assessment and plan of care) on the basis of criteria established by CMS.

The Comprehensive Assessment/Plan of Care is completed in the EMR.

Unstable Care Plans

Patients determined to be unstable require monthly assessments based on criteria established by CMS; and charting the timelines for improvement in specific benchmarks of care (e.g., adequacy, anemia, volume, etc) depending on the patient’s key issues.

Each member of the interdisciplinary team will need to complete their section of the Unstable Care Plan in the Discipline Centric portion of the electronic medical record by the 15th of the month. (See attached policy: Patient Care Plans-Unstable). You will subsequently participate in a discussion regarding the patient’s plan of care and sign the final document.

Chronic Renal Disease Medical Evidence Report (CMS 2728 Forms)

These green forms enroll all patients in the ESRD program, provide for Medicare entitlement if the patient is under 65, and generate important epidemiologic information for the USRDS and Networks. The Northwest Kidney Centers CIS team (Clinical Iformatics) completes these forms using the information provided on the referral form. It is crucial that you complete all information on the referral form to enable Northwest Kidney Centers to submit these essential documents promptly, maintain their accuracy, minimize telephone calls asking you for further information, and most importantly, ensure that your patients get the benefits they need.

Catheter Surveillance and Reduction Program

In order to reduce the number of catheters, NKC has created a tool showing the number of days a catheter has been in place. Part of the care conference with the Medical Director of each facility will address access removal using this tool. Close attention will be given to patients with catheters of extended vintage (particularly >90 days). For patients with catheters in >90 days, the NKC Case Manager will communicate with you regarding the plan for catheter removal as well as the overall access plan.

Challenging Patient Program

The Challenging Patient Program provides staff with clear and concise guidelines on how to deal with a challenging patient who is abusive, threatening, and/or exhibiting violence toward staff, patients or others. NKC does not allow weapons of any type on our properties. We take seriously any violence or threats of harm. Following our Challenging Patient Program assists us in responding in a consistent and thoughtful manner with safety in the unit a primary goal.

CKD – Chronic Kidney Disease Education Program

Patient education is an integral part of high-quality patient care. The CKD Education Program aims to support patients through the continuum of care—from the early stages of CKD to advanced kidney failure, through dialysis and transplant.

Patient-centered, evidence-based, health literate and culturally appropriate education is provided for patients to make informed decisions and is proven to improve patient outcomes.

CKD classes are offered several times each month at multiple locations and virtually, as well as individual sessions for patients who require interpretation or may not be classroom appropriate (e.g. mental health, special needs). Classes offered are:

1. Eating Well, Living Well nutrition education provides education about a kidney friendly diet. Attendees learn about foods that are good for the kidneys and heart healthy, about protein, potassium and phosphorous, as well as tips for shopping, cooking, and dining out. Instructors discuss hidden sources of salt and low-salt alternatives, giving patients the tools they need to create tasty, kidney-friendly meals.
2. Choices modality education informs patients and families about kidney disease basics, dialysis treatment options, including transplant and supportive care, as well as how to plan and prepare for treatment. Discussions include selecting the best modality for the patient’s lifestyle, desired outcomes and personal goals.
3. Next Step classes for Home Hemodialysis, PD and Transplant are for people with kidney disease who have attended our Choices class as well as current dialysis Through Next Step Home Hemodialysis and Next Step PD classes, patients gain more in-depth information about dialyzing at home, see the equipment and supplies, and tour the training units. In Next Step Transplant class, patients learn more about the evaluation, how to prepare, living and deceased donors, and the wait list.

Refer by faxing the Referral for CKD Services form with supporting records to the number on the form or phone the CKD Program at (206) 292-2771, ext. 1082. Physicians Forms – CKD Services Referral Form (nwkidney.org).

Hospital Services

Provides high quality comprehensive, cost-effective renal replacement therapy and related extracorporeal therapies to hospitalized patients at contract hospitals/medical centers. Treatments available include hemodialysis, hemoperfusion, isolated ultrafiltration, and CRRT (Continuous Renal Replacement Therapy).

Kidney Palliative Care Program

All Northwest Kidney Centers patients have access to outpatient palliative care to address a range of palliative care needs, including advance care planning, goals of care, advice on symptom management, and support for grief. At this point in time, the Kidney Palliative Care Team sees patients primarily by video with possibility for in person meetings on a case-by-case basis. When referring a patient, please state the palliative care need, a very brief explanation about the overall situation and please include your best estimate of prognosis. Normal time between referral and first contact is ~2 weeks. If your referral is more urgent, please communicate that information. You may refer a patient to any member of the Kidney Palliative Care (KPC) Team by phone 206.720.8675 or email or use the team email palliativecare@nwkidney.org.

Language Translation

Language translation services are available to rounding physicians. Each facility (with the exception of Port Angeles) has a Stratus InDemand cart for audiovisual interpretation. In addition to having the most common languages available by audiovisual interpreter access, more than 200 other languages are available via voice only. NKC also has a dedicated telephone line to access an interpreter: 206-880-7415.

Typically, the InDemand cart or telephone is used for planned conversations of 30 minutes or less, or whenever there is unanticipated need for interpretation. If a longer session is anticipated, NKC will arrange for an in-person interpreter to come onsite. Dialysis staff can assist you with in-person, InDemand, or telephone interpreter access.

New Patient Education

Northwest Kidney Centers staff teach new patients about their illness and treatment during a 6-8 week program. They are given information about all NKC services and education about kidney failure. A plan for long-term treatment is made at this time.

Nutrition and Fitness Services

Offers detailed information on the best diet choices for a patient’s individual needs. Provides referrals and resources to help patients maintain the strengths they have and regain lost physical abilities. For CKD patients, they can receive services through our CKD department (see CKD services).

Patient Finance

Patient Finance has two main roles:

1. Registration and Insurance Coordinators (RICs) verify eligibility of insurance policies and RICs requests and obtains prior authorization as required. RICs maintain patient registration in TIME (demographics and policy updates).
2. Financial Case Managers (FCMs) assist patients in meeting their obligation to obtain and maintain all eligible findings to minimize charity, bad debt, and any personal balances. FMCs manage caseloads to ensure that finding is in place for all assigned dialysis and transplant FMCs conduct initial and ongoing patient financial evaluations to assess the funding needs and counsel patients and families on finding options as necessary. They are knowledgeable about Medicare, Medicaid, insurance issues, the best resources for low-cost medications and how to apply for funding.

Pharmacy

The NKC Pharmacy specializes in the drugs required by dialysis and kidney transplant patients. With a focus on personal service, pharmacists fill prescriptions, and provide drug information and education to patients. Prescriptions can be picked up at the pharmacy, delivered to the patient’s dialysis unit, or mailed to the patient’s home.

Social Services

Assist patients and families in adjusting to chronic illness, maximizing their quality of life, and pursuing life goals. Social workers address barriers to patients following their treatment plan— both external and internal. This includes problem solving with patients their transportation to/from dialysis. Social workers take the lead in communicating with transplant programs and tracking transplant status.

Special Care

Special Care is an outpatient dialysis program in some of our clinics that includes highly skilled nursing care, personal care assistance, management of multiple medications, greater staff to patient ratio than available in a community dialysis unit, majority licensed nursing staff, proactive care coordination across multiple settings (including nursing homes and hospitals), care planning and end of life family consultation, chaplaincy service, palliative care consultation, hospice coordination and a bed during treatment.

The medical director, clinical director or their designee of each special services unit will make the decision before admission whether or not to accept a new or transferred patient. The chief medical officer and chief nursing officer will be consulted as needed.

Patients most suitable for Special Care usually need several or more of these services:

1. Two-person transfer assistance from stretcher or wheelchair
2. Higher level of surveillance, detecting subtle, rapid and frequent changes in status than normally a dialysis technician in an outpatient unit can safely provide
3. Frequent comprehensive physical assessments
4. Regular monitoring of hypotension and chest pain
5. Frequent interventions during dialysis for hypotensive episodes
6. Management of multiple medications during a visit
7. Personal needs care that requires skilled nursing assistant-level skill
8. Staff knowledge about how to work with patients with medical devices e. ostomy tubes, tracheotomy tubes, etc
9. A bed for medical necessity
10. Private rooms with adjacent bathroom for patients positive for C-difficile with uncontained diarrhea
11. Ventricular assist devices

Exclusion criteria for Special Care:

1. Ventilator dependent
2. Dependent on others for tracheostomy suctioning
3. Need continuous cardiac monitoring during dialysis due to inotropic agents
4. Are in a persistent vegetative state before starting treatment
5. Regularly require one-on-one or one-to-two staff to patient ratio

As with other NKC units, patients will not be admitted if they:

1. Have active tuberculosis
2. Meet other medical or behavioral exclusion criteria for outpatient dialysis
3. NKC lacks capacity to care for the patient

Transplantation Education, Support and Status Tracking

Northwest Kidney Centers provides a comprehensive, ongoing program of patient treatment and education in support of transplantation and organ donation. This includes: providing pharmacy services for transplant patients under the care of the Northwest Kidney Centers medical staff; promoting transplantation through “Choices” and “Next Step Transplant” educational classes for patients; coordinating with hospital transplant programs, tracking the patient’s status in the EMR; assisting potential transplant recipients with insurance planning by financial counselors; providing transplant patients access to NKC emergency grants three years post-transplant; highlighting organ donation and transplant at public awareness events.

Transportation

The Patient Services Coordinator assists patients in setting up transportation for their dialysis. Standing rides to and from dialysis can be made for patients with eligible Medicaid or disability qualifications. The Transportation phone number is 206-292-2704.

Visitor Dialysis

The Visitor Dialysis Coordinator handles all dialysis requests from non-NKC patients who require dialysis while visiting our area. This includes patients temporarily in the area for medical reasons, and non-NKC patients incarcerated in the King County Jail. Thirty days advance notice is required in order to schedule visitor treatments. Exceptions can be granted in case of a death in the family or urgent medical need.

Zero Tolerance weapons policy

NKC has a zero tolerance for weapons and violence policy that includes rules that all patients, staff and visitors must follow.

All Forms and Reference Materials: All Physicians’ Forms | Northwest Kidney Centers (nwkidney.org)

• Chief Medical Officer – Matthew Rivara, MD matthewr@nwkidney.org
• Executive Assistant to the Office of the CMO -Sarah Schulhauser, schulhauser@nwkidney.org
• Compliance Lead- Contracts and Credentialing- Michael Oliva, oliva@nwkidney.org
• Credentialing -credentialing@nwkidney.org
• NKC Support, support@nwkidney.org