EQRS Quarterly Highlights
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Clinical Depression Dashboard Released
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On June 24, 2024, the Centers for Medicare & Medicaid Services (CMS) released a new Clinical Depression Dashboard in the End Stage Renal Disease (ESRD) Quality Reporting System (EQRS).
The new Facility Clinical Depression Dashboard provides dialysis facility users and dialysis organizations with up-to-date information and visualization on ESRD patient clinical depression data in-use at an individual facility or, when applicable, throughout the dialysis organization. Using an easy-to-use, intuitive dashboard interface, users can view clinical depression screening data on an individual or aggregate basis for any individual year.
The dashboard allows users to select a reporting period and display the number and percentage of patients at the facility with a depression screening reported in EQRS at the time the report is generated (Figure 1) and at the National level (Figure 2).
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Figure 1. Facility-level Clinical Depression Screening Results
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Figure 2. National-level Clinical Depressions Screening Results
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Users may also view a facility summary table and patient summary table for each facility under their purview. The facility summary table displays a summary of the facility’s depression screening results including the total number of patients, number of patients screened, number of missing screenings, and results of the screenings among those screened.
The patient data table contains all individual patient depression screening details that contribute to the graphs and data displayed on the dashboard. Users may filter this table by EQRS unique patient identifier (UPI), whether or not a screening was submitted, or by depression screening results.
More information regarding this dashboard can be found here.
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Upcoming Events & Registration Links
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To stay informed on developments related to EQRS, check out the Events page on MyCrownWeb.org where events and topics are posted in our Monthly EQRS Stakeholder Webinars and other ESRD QIP related webinars. These monthly webinars will provide EQRS users with the latest updates as well as offer EQRS users the opportunity to engage in live Q&A sessions with our EQRS experts.
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Calendar Year (CY) 2025 ESRD Prospective Payment System (PPS) Proposed Rule Published
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In the CY 2025 ESRD PPS proposed rule, CMS proposed two changes to ESRD QIP measures.
First, CMS proposed to remove the Kt/V Dialysis Adequacy Comprehensive clinical measure and replace it with the Kt/V Dialysis Adequacy Measure Topic, which consists of four individual Kt/V measures (i.e., adult hemodialysis (HD) Kt/V, adult peritoneal dialysis (PD) Kt/V, pediatric HD Kt/V, and pediatric PD Kt/V).
Additionally, CMS proposed the removal of the National Healthcare Safety Network (NHSN) Dialysis Event (DE) reporting measure.
CMS also sought input regarding possible adjustments to scoring, which may include incentivizing facilities based on their performance and proportion of their patients who are dually eligible for Medicare and Medicaid, as well as on the data validation policy aimed at promoting accurate and comprehensive reporting of ESRD QIP data.
These proposed changes were presented in a webinar on Tuesday, August 13th. Slides and recordings are available here. To access the proposed rule, click here.
The July Monthly EQRS Stakeholder Meeting was held on Tuesday, July 30th. The meeting encompassed an overview of EQRS including user roles, functionality and resources, applying for EQRS access, basic data entry requirements and a review of the facility, vascular access and clinical depression dashboards. For more information on this meeting, you may access the recording here.
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End Stage Renal Disease Quality Incentive Program (ESRD QIP) Preview Period Ended
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On Monday, July 15th, CMS kicked off the payment year (PY) 2025 preview period. This was your opportunity to preview your facility’s PY 2025 Performance Score Report (PSR) and Patient List Report (PLR) for PY 2025.
The preview period ended on August 15, 2024.
CMS is in the process of responding to all inquiries and finalizing scores in preparation of releasing the final PY 2025 ESRD QIP reports in the fall. Once released, facilities are required to download and display their Performance Score Certificate (PSC) in a prominent location where patients may view the report.
For more information on this year’s Preview Period, you may access the recording from the July 16th Preview Period Webinar here.
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Be on the lookout for the announcement of final reports & remember to download and post your PSC within 15 days of the release of final scores!
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Updated Form CMS-2728 Available in EQRS for Use: October 1, 2024
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On October 1, 2024, the updated ESRD Medical Evidence Report for Medicare entitlement and/or patient registration (Form CMS-2728) will automatically generate in the EQRS Patient Registry application whenever an Initial, Re-entitlement, or Supplemental Form CMS-2728 is added.
This form can be accessed on CMS.gov in advance of the system release here.
For additional information on the Form CMS-2728 updates, refer to the Form CMS-2728 Updates Reference Guide and Frequently Asked Questions (FAQs).
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Updated Form CMS-2746 Available in EQRS For Use: October 1, 2024
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On October 1, 2024, the updated ESRD Death Notification Form (CMS-2746) will automatically generate in the EQRS Patient Registry application whenever a CMS-2746 is added.
This form can be accessed on CMS.gov in advance of the system release here.
For additional information on the Form CMS-2746 updates, refer to the Form CMS-2746 Reference Guide.
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Remaining EQRS & NHSN Data Submission Deadlines for CY 2024
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Dialysis facilities must submit ESRD data by the deadlines listed below. Failure to submit the required data by these deadlines puts your facility at risk for an ESRD QIP payment reduction.
Please note that if the last day of the month falls on a Friday, Saturday, Sunday, or federal holiday, the deadline will occur on the next federal business day. The data submission deadlines apply to all collection types (Hemodialysis and Peritoneal Dialysis) and to all submission methods.
CMS strongly recommends that facilities complete large data submissions and audit batch submitted data prior to data submission deadlines.
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EQRS Data Submission Schedule
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Reporting Month
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Data Submission Deadline (by 11:59 PM PT)
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July 2024
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Monday, September 30th, 2024
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August 2024
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Thursday, October 31st, 2024
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September 2024
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Monday, December 2nd, 2024
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October 2024
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Tuesday, December 31st, 2024
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November 2024
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Monday, February 3rd, 2025
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December 2024
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Monday, March 3rd, 2025
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Clinical Depression Screening, Follow-up Assessments, ICH CAHPS Facility Attestation, & Commitment to Health Equity Attestation
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Assessment/Attestation Period
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Data Submission Deadline (by 11:59 PM PT)
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January 2024 – December 2024
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Monday, March 3rd, 2025
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NHSN Deadlines for 2024 ESRD Data
(BSI in Hemodialysis Patients, Dialysis Event Reporting, & COVID-19 Vaccination Coverage Among Healthcare Personnel)
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Quarter
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2024 Reporting Month
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Data Submission Deadline (by 11:59 PM PT)
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2
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April – June
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Monday, Sept. 30th, 2024
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3
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July- September
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Tuesday, Dec. 31st, 2024
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4
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October- December
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Monday, March 31st, 2025
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For assistance with EQRS technical issues, please contact the Center for Clinical Standards and Quality (CCSQ) Service Center. The CCSQ Service Center is open Monday-Friday 8 AM to 8 PM Eastern Time and can be reached via phone at 866-288-8912, email at qnetsupport-esrd@cms.hhs.gov or online at the CCSQ Support Center.
For assistance with general EQRS and ESRD QIP questions, please contact the ESRD QIP Team via the QualityNet Q&A Tool.
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