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Patient and Family Engagement (PFE)

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Centers for Medicare & Medicaid Services (CMS) recognizes that patients, families, and caregivers are essential partners in the effort to improve the quality and safety of healthcare provided to all patients. It is only by including them as active members of their own healthcare team that quality can be improved and care become more patient-centered; by fully engaging patients, families, and caregivers in the design, delivery and evaluation of care, it is made safer, treatment plan adherence is increased, and hospital readmissions are reduced.

The resources found on this page can help both patients and dialysis facility staff, as part of the healthcare team, fully engage in the process for quality improvement.

For Providers

The following resources can be used to engage patients in the facility’s QAPI program, Life Planning and to find support outside of the facility.

The ESRD Network’s Peer to Peer Support Program was developed to match trained Peer Mentors with Peer Mentees that are new dialysis, considering a treatment change or who are just interested in talking with another dialysis or transplant patient to ask questions or discuss their experience. This section includes all of the information and forms the dialysis facility, Peer Mentor or Peer Mentee needs to get started.

What is Peer Mentoring?

A peer mentor empowers fellow patients to move forward and cope with their lives after being diagnosed with ESRD. Peer mentoring:

  • Helps patients understand the benefit of controlling their health and being involved in their care, which can result in patients living longer and healthier lives.
  • Closes the gap in communication with dialysis staff in an effort to ensure that staff understand patients’ concerns, issues, and priorities.
  • Provides support and increases the confidence that many new patients need.

What are the benefits of Peer Mentoring?

  • Patients may have family and friends to assist with their new diagnosis. However, it helps to have someone who has been through the same experience and has a good understanding of all that dialysis involves.
  • For those who do not have friends or family to assist them, Peer Mentors can be essential in providing strong support.

What is the role of a Peer Mentor?

Peer mentors can have several roles, including:

  • Providing information.
  • Listening to concerns.
  • Sharing experiences.
  • Promoting positive behavior.
  • Offering encouragement.
  • Relieving anxiety.

Who should be a Peer Mentor?

  • Peer Mentors can come from all backgrounds. Mentors should be individuals with positive outlooks on managing kidney disease.
  • Individuals who are succeeding at achieving their treatment goals can provide insight to help others successfully manage kidney disease.

I want to start a peer mentoring program at my facility. Where do I begin?

  • The ESRD Network is available to support you with starting a Peer Mentoring program at your facility.
  • The HSAG ESRD Network Peer Champion can provide you with the resources to identify Peer Mentors and Peer Mentees and then can take it from there to make the Peer connections. 
  • The HSAG ESRD Networks also have a closed Facebook Dialysis Peer Support Group that some patients may be interest in participating in.
  • Contact the HSAG ESRD Network Peer Champion via:

Additional Peer Mentoring Resources

Listed below are support groups and peer mentoring programs for dialysis patients.​ Some national, nonprofit organizations also have websites devoted to educating and empowering those with kidney disease.​​

Please see below best practices for implementing PFE activities at the facility level.

Patient Engagement in Development of the Individualized Plan of Care and Plan of Care meetings:

  • Facilities are encouraged to continue to invite patients to POC meetings via telephone or other virtual means.  
  • Continue to engage patients in their overall Plan of Care by speaking with them about their goals and concerns.
  • Incorporate how the patient is dealing with the COVID-19 pandemic into the Plan of Care. For example:
    • Is the patient practicing physical distancing outside of the facility?
    • Is the patient having issues with childcare related to school closures?
    • Are they having issues with wearing face coverings consistently when there is a risk of exposure?
    • Are their family/caregivers/roommates following recommended COVID-19 safety measures as well?
    • Does the patient have access to food or medicine?

Engaging Patients in Quality Assessment and Performance Improvement (QAPI) Meetings or the Governing Body:

  • In lieu of inviting patients to in-person QAPI or Governing Body meetings:
    • The patient could attend via phone or other virtual means.
    • A staff member could speak with the patient(s) about their ideas and bring those ideas to the QAPI meeting on the patient’s behalf. The staff member should follow-up with the patient after the QAPI or Governing Body meeting is conducted to discuss next steps.  
       

Establishing Patient Support Groups:

The Department of Health and Human Services National Quality Strategy’s new focus on better care for the individual through beneficiary- and family-centered care involves working with patients rather than doing to or for patients. Such partnerships are mutually beneficial to the patients and the facility. Involving patients in your facility’s QAPI and/or Governing Body meetings can be an effective means of engagement and partnership. Below are some tools to help you get started.

Helpful Documents:

Network 7

Network 13

Network 15

Network 17

Continuing Education Courses:

  • QI: Culture of Change
    The purpose of this course is to provide a basic understanding of continuous quality improvement (CQI), while also addressing the stages of change. 1 Continuing Education (CE) Credit
  • Understanding Rapid Cycle Improvement
    This course aims to improve your knowledge of quality improvement by explaining each step of the improvement model and directing you to pro-actively improve care processes. 3 CE Credits 

PFE Webinars:

Other Resources:

There is strong evidence that peer support can help:

  • Patients to manage chronic diseases like ESRD,
  • People to cope with stress or emotional and psychological challenges
  • Engage populations that are not always reached through interventions
  • Reduce unnecessary hospital admissions for the same problem.

Peer support is generally cost-effective and provides a personal connection that helps patients to better understand their health and expand their role in guiding their own care.

The resources below can help you to establish peer support groups in your facility(ies).

PFE Webinars

Documents

COVID-19 Support Groups

Online and Telephone Support Group Resources

The websites listed below specialize in kidney disease. Many offer education, as well as the opportunity to connect with other end stage renal disease (ESRD) patients, family members, and/or caregivers through discussion forums and subscription-based email lists. When looking for resources, please be aware that anyone can create a website and only visit reputable sites! When searching, use keywords such as “kidney disease” or “dialysis” to find related groups. When in doubt, always consult your healthcare team.

  • Renal Support Network (RSN) HOPEline
    The RSN HOPEline has helped thousands of people through peer-to-peer support. Available to people with chronic kidney disease, family members, and caregivers, the HOPEline  helps people connect with another person who has lived with kidney disease and can share their experience, strength, and hope, and what they have done to navigate this illness successfully. RSN Facebook Page

  • American Association of Kidney Patients (AAKP) Community
    AAKP recognizes the value of local patient support groups and through its website and various publications, provides a centralized resource to locate support groups in their communities.
  • Helparound Application, NXStage
    Helparound aims to help chronic patients and their support systems, overwhelmed by a life-changing condition, to simplify the day-to-day of managing treatment by magically delivering the information and support resources they need, when they need them, through their smartphones.
  • Home Dialysis Central Forums
    Home Dialysis Central is a one-stop resource for patients and professionals who want to learn more about home dialysis options—what they are, where you can find them, and why you might want to choose one over another. You can get advice from experts or other members of the home dialysis community, or you can share your knowledge with others. This site is an online discussion forum.
  • Home Dialysis Central Discussion Group on Facebook 
    This is a moderated private Facebook group. You can ask anything without worry. Group members are kind, smart, helpful, and respect each other. They welcome dialyzers, caregivers, and others for support, information, and help coming to grips with dialysis in any of its forms.

  • National Kidney Foundation (NKF) of Louisiana
    https://www.kidneyla.org/                                                          https://www.facebook.com/NKFLA
    NKF of Louisiana website and Facebook page offers information about events, education, and access to an online ESRD community
  • Nephkids Cyber-Support Group
    Nephkids is cyber-support group for parents of children with CKD. It offers an interactive email group (listserv) for parents of children with all types of chronic kidney disease.
  • NKF Peers Lending Support
    1. 855.653.7337 (1.855.NKF.PEER)
    This website from the NKF is for a new patient program that connects people needing support with peers who “have been there.”

The POC meeting is an ESRD Patient's opportunity to communicate directly with his or her healthcare team about decisions that affect their dialysis care. It is the patient's opportunity to learn more about ESRD and how his or her choices can affect various aspects of treatment. The information provided here will help you to engage more patients in their POC meetings.

PFE Webinars

  • POSTER/FLYER: PAC Kidney Month (Poster/Flyer)
  • POSTER: Respect in the Facility (English/Spanish)
  • Good Relationships With Your Clinic (English/Spanish)
    This resource is intended for both patients and staff. You spend a lot of time together, so good relationships with your dialysis staff are important to you and to them. All people want to feel safe, respected, and trusted when working together. One way to do this is by setting "healthy boundaries." This resource discusses what boundaries are, what they do, why they are important, and what to do if a boundary ever gets violated. 
  • Patient and Family Engagement
    Agency for Healthcare Research and Quality (AHRQ) ESRD Toolkit
  • Person-and Family-Centered Care
    This web page from the Institute for Healthcare Improvement (IHI) is dedicated to putting the patient and family at the heart of every healthcare decision and empowering them to be genuine partners in their care.
  • Partnership for Patients
    The website for the Health and Human Services (HHS) public-private partnership that works to improve the quality, safety and affordability of healthcare for all Americans.
  • The Forum of ESRD Networks
    This not-for-profit supports and advocates for the ESRD Networks in their efforts to monitor the quality of chronic kidney disease, dialysis and kidney transplant care.
  • Taking Charge of Your Healthcare: Your Path to Being an Empowered Patient 
    From Consumers Advancing Patient Safety (CAPS), this is a comprehensive toolkit that can be used by providers during hospital discharge to help patients leave the hospital with confidence.
  • Tips to Improve Patient Engagement at the Facility Level
    Tips that can assist your staff to establish the genuine engagement with patients that is essential in the provision of high-quality healthcare and to achieve improved healthcare outcomes.
  • Conflict Resolution Tip Sheet
    This document provides tips to foster a positive and productive conflict resolution meeting.

Peer Mentoring Templates
Brand these templates with your logo and use them to inform patients about peer mentoring and to elicit feedback and interest.

Videos

For Patients, Families, and Caregivers

The following resources can be used by patients, families and caregivers to find support outside of the dialysis facility.

The ESRD Network’s Peer to Peer Support Program was developed to match trained Peer Mentors with Peer Mentees that are new dialysis, considering a treatment change or who are just interested in talking with another dialysis or transplant patient to ask questions or discuss their experience.  This section includes all of the information and forms a dialysis or transplant patient needs to become a Peer Mentor or Peer Mentee.  

Peer-to-Peer Background and Overview

What is Peer Mentoring?

A peer mentor empowers fellow patients to move forward and cope with their lives after being diagnosed with ESRD. Peer mentoring:

  • Helps patients understand the benefit of controlling their health and being involved in their care, which can result in patients living longer and healthier lives.
  • Closes the gap in communication with dialysis staff in an effort to ensure that staff understand patients’ concerns, issues, and priorities.
  • Provides support and increases the confidence that many new patients need.

What are the benefits of Peer Mentoring?

  • Patients may have family and friends to assist with their new diagnosis. However, it helps to have someone who has been through the same experience and has a good understanding of all that dialysis involves.
  • For those who do not have friends or family to assist them, Peer Mentors can be essential in providing strong support.

What is the role of a Peer Mentor?

Peer mentors can have several roles, including:

  • Providing information.
  • Listening to concerns.
  • Sharing experiences.
  • Promoting positive behavior.
  • Offering encouragement.
  • Relieving anxiety.

Who should be a Peer Mentor?

  • Peer Mentors can come from all backgrounds. Mentors should be individuals with positive outlooks on managing kidney disease.
  • Individuals who are succeeding at achieving their treatment goals can provide insight to help others successfully manage kidney disease.

Peer Mentor Requirements

  • Over 18 years old​.
  • Received dialysis treatment for at least one year​.
  • Completed the Peer Mentoring training modules.​
  • Completed the Network application and signed agreement form​.

Peer Mentees Requirements

  • New to dialysis or interested in home dialysis/transplant​.
  • Completed the Network application and signed agreement form.​

I want to start a peer mentoring program at my facility. Where do I begin?

  • The ESRD Network is available to support you with starting a Peer Mentoring program at your facility.
  • Dialysis or transplant patients can participate by:
    • Becoming a Peer Mentor.
    • Being matched with a Peer Mentor for support.
    • Joining the HSAG ESRD Network closed Facebook Peer Support Group.
  • Talk with your Social Worker or a facility staff member about your interest in Peer Mentorship and starting a program for your facility. 
  • Contact the HSAG ESRD Network Peer Champion to get more information via:

HSAG ESRD Network Peer to Peer Support Program Resources

  1. 2023 Peer-to-Peer Agreement Form
  2. HSAG ESRD Network Peer-to-Peer Program Flyer
  3. HSAG ESRD Network Facebook Dialysis Peer Support Group Flyer
  4. HSAG ESRD Network Patient Volunteer Interest Form
  5. ESRD Network National Coordinating Center (NCC) Peer Mentoring Resources

How to begin as a Peer Mentor

  1. Watch this Peer-to-Peer Program video to understand how the Peer-to-Peer program works, instructions for the 2023 Peer-to-Peer agreement form, NCC trainings, and HSAG Peer Support Facebook Group.
  2. Have the Facility Social Worker fax your completed Peer to Peer Agreement form to the Network.
  3. Register via computer or smart phone on the ESRD National Coordinating Center’s Kidney Learning Hub: www.kidneylearninghub.com (the register link is in the top right corner)
    • After you complete the short registration page, you will receive a confirmation email.
    • To complete the registration, you will need to click on the link in the email.
    • You can use the Kidney Learning Hub User’s Guide if you need assistance:  Kidney Learning Hub User Guide.pdf
    • If you have any issues with the NCC website, you can watch this brief video tour.
  4. Complete Learning Modules 1, 2 and 3 on the NCC’s Kidney Learning Hub patient courses. Each module has a short test associated with it.
  5. Following completion of the modules, the ESRD Network will reach out with a completion certificate and to discuss next steps.

COVID-19 Support Groups

Documents

  • Facilitating an ESRD Support Group
    This  document can help you if you are interested in starting a support group. It defines what a support group is, why it is difficult to find a support group, how to start one, as well as providing tips for running support group meetings.

Groups

  • Renal Support Netword (RSN) HOPEline
    The RSN HOPEline has helped thousands of people through peer-to-peer support. Available to people with chronic kidney disease, family members, and caregivers, the HOPEline  helps people connect with another person who has lived with kidney disease and can share their experience, strength, and hope, and what they have done to navigate this illness successfully.

  • American Association of Kidney Patients (AAKP) Community
    AAKP recognizes the value of local patient support groups and through its website and various publications, provides a centralized resource to locate support groups in their communities.

  • Home Dialysis Central Forums
    Home Dialysis Central is a one-stop resource for patients and professionals who want to learn more about home dialysis options—what they are, where you can find them, and why you might want to choose one over another. You can get advice from experts or other members of the home dialysis community, or you can share your knowledge with others. This site is an online discussion forum.

  • Home Dialysis Central Discussion Group on Facebook
    This is a moderated private Facebook group. You can ask anything without worry. Group members are kind, smart, helpful, and respect each other. They welcome dialyzers, caregivers, and others for support, information, and help coming to grips with dialysis in any of its forms.

  • National Kidney Foundation (NKF) of Louisiana
    https://www.kidneyla.org/                                                          https://www.facebook.com/NKFLA

    NKF of Louisiana website and Facebook page offers information about events, education, and access to an online ESRD community
  • Nephkids cyber-support group
    Nephkids is cyber-support group for parents of children with CKD. It offers an interactive email group (listserv) for parents of children with all types of chronic kidney disease.

  • NKF Peers Lending Support — 1.855.653.7337 (1.855.NKF.PEER)
    This website from the NKF is for a new patient program that connects people needing support with peers who “have been there.”

  • Renal Support Network (RSN) — HOPEline 1.800.579.1970
    The RSN website empowers people who have kidney disease to become knowledgeable about their illness, proactive in their care, hopeful about their future, and to make friends through informative, patient-directed programs.
    RSN Facebook Page

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