my clinic plan checklist and outline - Heartland Kidney Network

“My Life, My Choices: Knowledge is Power”
MY KIDNEY KIT
My Clinic Plan
The Network has an overall plan to the implementation of the “My Life, My Choices: Knowledge is Power” Network Project
with My Kidney Kit being one aspect of Phase I. In order to assist facilities in meeting the goals of this Network-wide
project we would like to offer an outline for implementation.
□ Complete a Network Project Commitment Form
□ Identify your Clinic Contact (this may be your Facility Representative)
My Clinic Contact is _____________________________
□ Identify a Network Patient Representative to serve as an ambassador for the Network and assist with the
promotion of the project with the clinic.
My Network Patient Representative is ___________________________________
□ Patient has agreed and completed the Application
□ Clinic staff have completed the Nomination form
□ Packet has been sent to the Network
□ Sign up for the e-newsletter in order to receive updates and additional resources
□ Identify 10% of your clinic patient population to participate
□ Complete pre-program evaluations with participating patients and submit to the Network
□ Utilize the Monthly Outline to provide collaborative education with the participating patients
□ Complete the My Education Sheet with participating patients following each Collaboration Session
Record the “teach back” in the patient’s words
Submit documentation of completion to the Network on a Quarterly Basis
□ Complete post-program evaluations with participating patients and submit to the Network
□ Participate in WebEx sessions on topics such as Patient Engagement, Health Literacy and Patient Perspective
□ Provide valuable input to the Network in order to spread best practices
□ Share resources with the Network to be shared with the renal community

“My Life, My Choices: Knowledge is Power”
MY KIDNEY KIT
Monthly Outline
MONTH SECTION MY PAGES
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
MY NETWORK
MY LIFE
MY CHOICES
MY TREATMENT
MY PLAN
NEW TOPICS
& REVIEW
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Dialysis Facility Compare (DFC)
Grievances
Medicare Part D
Patient Advisory Committee
The Heartland Kidney Network
Your Rights & Responsibilities
Coping with Dialysis
Healthy Lifestyle Choices
Occupation
Vaccines
Kidney Transplant
Peritoneal Dialysis (PD)
Self-Cannulation
Types of Hemodialysis
What I Should Know about Fistulas
Albumin
Am I getting Enough Dialysis?
Anemia
Fluid Weight and Dry Weight
Knowing My Lab Numbers
Medication Safety
My Dialysis Team
Renal Bone Disease
□ Diabetic 3-Day Emergency Diet
□ Dialysis Emergency Takeoff
□ How Do I Control My Fluid Gains?
□ How I Disinfect My Drinking Water
□ In Case of Emergency
□ Making My Wishes Known
□ Pediatric 3-Day Emergency Diet Menu
New Pages developed by the Network and Pages identified for
individual patient’s review.