Increasing Patient and Family Engagement (PFE) and Improving  Patient Experience of Care

The Centers for Medicare and Medicaid Services' main focus in all quality improvement activities (QIAs) is patient engagement.  Research has shown that facilities with patients whom are active members in their healthcare, achieve better clinical outcomes.
As a valuable participant of the healthcare team, patient advocates empower patients with renal failure to move forward with their lives after being diagnosed with kidney disease. They serve as a bridge for better communication with medical staff, which assures a better understanding of patients' concerns, issues, and priorities.
The Network hopes to bolster patients and family engagement at the facility level as they become active partners of the healthcare team. This will be accomplished through the disbursement of marketing and campaign materials, education, and peer-to-peer counseling.

Tools & Resources

This initiative will embody a campaign model in which grass root recruitment materials will be distributed to all facilities in the Network, with a concentrated focus on facilities involved in quality improvement activities. Materials are to include both print and digital marketing materials inspiring all patients and to nominate either themselves or other patients within their facility to become a patient ambassador. Once a patient has been recruited, the new recruit will be advised of their roles and responsibilities as peer mentors through detailed training.

CMS Conditions for Coverage for end-stage renal disease facilities. Subpart C - Patient Care

What is Peer Mentoring?

A peer mentor empowers fellow patients to move forward with their lives after being diagnosed with ESRD. Peer mentoring provides support and increases the confidence that many new patients need, and offers patients access to someone who can understand their concerns. Your peers may get support from friends and family, but connecting with others who have similar experiences can offer added 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.

Plan of Care Meetings

You can involve family members and care partners in patient plan of care (POC) meetings via telephone... patients too!

Part of the responsibility of the interdisciplinary team (IDT) is to include patients, and if requested, their care partners and family members in both developing/setting goals and reviewing the patient plan of care.

Is it acceptable to hold a plan of care meeting with the IDT and the patient, their care partner or family members (if requested) via telephone conference? As stated in the CMS Interpretive Guidance for the Conditions for Coverage for End-Stage Renal Disease Facilities, the answer is "yes."

"A substitute mechanism for a team conference needs to facilitate discussion among team members about the information gathered from the comprehensive patient assessment and provide the opportunity for team coordination and development of an effective, individualized plan of care for the patient to ensure the desired outcomes are achieved. To facilitate full team participation in conferences, any member, including the patient, may participate through telecommunication."


Our goal is to create a culture of shared responsibility for improvement within the facility. Healthcare that results in the best outcomes revolves around teamwork. The Network aims to help create an environment where patients are a part of the healthcare team. Facilities can adopt this method to continue to increase patient engagement.

  • Project participating facilities to implementation an internal policy and procedure and/or the development of a policy and procedure in regards to inviting patients, family members, or caregivers to be included in their plan of care
  • Identify an individual to serve as a patient ambassador

Improving patient and family engagement practices at the facility level will help with:

  • Establishing patient council support groups/ new patient adjustment groups
  • Incorporating patient, family and caregiver participation into the Quality Assurance Performance Improvement (QAPI) meetings and governing body of the facility
  • Developing policy and procedures related to patient, family and caregiver participation in the patient's care


  • Talk with dialysis team members and patients to identify root causes of barriers related to patient and family engagement.
  • Peer Mentoring Guidelines 


  • Identify an individual to serve as a patient ambassador in your facility by clicking here.
    Set up a patient support group to help orient new patients or open communication among peers.
  • Invite a patient to the beginning and/or end of a QAPI meeting to allow them an opportunity to voice their concerns.
  • Share PFE policy with patients at the facility
  • Identify an individual to serve as a patient ambassador in your facility by clicking here.
  • Set up a patient support group to help orient new patients or open communication among peers.


Nurse teaching Patient

For more information:

Brittney Jackson, LMSW, MBA
Patient Services Director

Merari Rosario, MHA
Community Outreach Coordinator