Network 4 Transplant Centers Current State and Program Highlights September 25, 2020 1:00 PM – 2:30 PM Housekeeping Items

• Type your questions into the “Chat” feature in your Webex player. • If you have a question for a specific person, please be sure to note that in your question. Welcome Agenda Panelists representing several transplant centers in the Central and Eastern parts of Network 4 service area: • Tower Health Transplant Institute – Karthik Ranganna, MD, MBA, FASN, FACHE, Medical Director, Kidney Transplant • Lehigh Valley Hospital Transplant Center – Tyler Baldes, MSW, LSW Transplant Social Worker • Pinnacle Health at Harrisburg Hospital Transplant Center – Rebecca Brown, MSN RN CCTC, Unit Director • Main Line Hospital Lankenau Transplant Center – Cara Morasco, Transplant Manager • Thomas Jefferson University Hospital Transplant Center –Joanne Weill-Greenberg, MSS, LSW, Transplant Social Worker • Temple University Hospital Transplant Center, Elizabeth Lowry, Transplant Outreach Education Coordinator • Transplant QIA Results – Kou Kha-Moua, Quality Improvement Director • Q&A Time COVID 19 and Kidney Transplant Program at Tower Health Transplant Institute COVID 19 and Berks County COVID 19 and Tower Health Hospitals

7 COVID 19 and Reading Hospital

8 Tower Health Transplant Program

• Started in October 2019

• Majority of the team came from The Hahnemann Transplant Program

• https://www.towerhealth.org/tower-health- transplant-institute/

9 10 11 OUR TRANSPLANT NURSE COORDINATORS

Saleema Brookins, BSN, RN Ruth Rowland, BSN, RN Marianne Watkins, RN OFFICE NUMBER: OFFICE NUMBER: OFFICE NUMBER: 484-628-7697 484-628-2436 484-628-7679 (Philadelphia) (West Reading) (Living Donor)

12 TRANSPLANT OUTREACH SOCIAL WORKER COORDINATOR

Renee Maggiaro, MSW, LSW Melissa Coleman OFFICE NUMBER: CELL NUMBER: 484-628-2348 267-438-5505

13 COVID 19 and Kidney Transplant Program

• In person evaluations were suspended in April 2020 in view of the COVID 19 pandemic

• Transplant patients were inactivated because of surge of cases in Reading hospital in April 2020 at the request of patients

• Plans were initiated to start the process of tele-evaluations of potential kidney transplant patients

• Conferred with programs like Vanderbilt which already have some form of tele-evaluations in place for some time

• Tele-video visits and some home blood draws established for post – transplant patients

14 COVID 19 and Kidney Transplant Program

• Protocols established in place for outpatient offices in the entire Tower Health System by end of May

• Started discussions on how to restart the kidney transplants safely during COVID 19 pandemic in end of April 2020

• All team members were involved – administration, facilities team, OR team, Floor nurses, infection control, physicians and surgeons

• Facility changes, new protocols established for ICU, floors, transportation of patients, labs, visitation…..

• Protocols established for recipient testing and immunosuppression and discharge plan and follow up

15 Our office is following COVID-19 Jul 7, 2020 Guidelines: Comments

16 COVID 19 and Kidney Transplant Program

• In person evaluation started in June 2020

• Education online by transplant coordinators before the evaluation in the beginning

• Review of consents by coordinators

• Tele-evaluations by social worker and financial coordinators

• Blood draws on a scheduled basis

• Plan to formalize tele-evaluation process as we move forward to limit travel for patients as much as possible during this period

17 Pre-emptive Telehealth Evaluations

Screen pre-emptive • Mail consent referral patients for packet & e-mail Call & review Schedule the following via link for consent via education video phone telehealth phone: • Request records (Patient to mail provider visit & • signed consents Telehealth eligibility for relevant SW phone call • back) Verify pre-emptive status testing • Prior relevant testing

Coordinator proceeds Coordinator to Coordinator SC with scheduling day 2 Approve SC present to notifies Turndow Decisio of evaluation testing / Decisio patient/referrin n (CXR, EKG, Labs, Pending Selection n n g/DU of decline Imaging, Cardiac Committee testing, Consults, etc.)

Approve Turndow n

• Coordinator notifies patient/referring/DU of Coordinator activation notifies • Patient is listed in UNOS patient/referrin (during COVID-19, will g/DU of decline petition to back date waitlist time to 1st Selection Committee Date)

The Tower Health Transplant Institute in West Reading reached a milestone on May 25 when the first organ transplant was performed at Reading Hospital. 21 Kidney Transplant Evaluations happen both in Philadelphia and in Reading

22 If you have patients currently interested in getting a Transplant Evaluation, please Fax a Face Sheet, 2728 CMS Form and the Evaluation Referral Form to Our Transplant Referral Line at: 484-628-2435

23 Advancing Transplants and Transforming Lives

• https://youtu.be/N2uRChTRK1Q

24 Transplant During the COVID-19 Pandemic How LVHN is Navigating the Virus

Tyler Baldes, LSW Transplant Social Worker

© 2018 Lehigh Valley Health Network Education

▪ Education sessions have switched from live group sessions to live Web Ex or phone sessions • Processes remain the same: patients proceed to scheduling an evaluation after completing the education session Evaluation

▪ Evaluation is largely unchanged ▪ Initially, evaluations were paused due to other testing sites being closed or limited. However, this is no longer the case. Evaluation

▪ Patients come to our office to meet with the team (social worker, financial coordinator, dietitian, nurse coordinator, and surgeon); will also get a chest XR, EKG, and blood work – about 4 hours – and will have a checklist of other testing to complete within about a 4 month timeframe ▪ We offer living donor evaluations in person or virtually. The education is done virtually for all high COVID areas. Waitlist

▪ Initially, we did not bring any patients in for organ offers if they were from NY or NJ, or if they had recently traveled there. This changed once COVID testing was more widely available. ▪ Some higher risk patients, such as HIV positive patients had been inactivated on our waitlist (meaning they still accrued time on the list but would not come up for transplant offers) • These patients are now reactivated Transplant Surgery

▪ Living donor surgeries were briefly paused due to being deemed voluntary. These have now resumed. (We did perform 1 LD surgery during this time but needed special approval— benefit of transplant outweighed the patient’s imminent need for dialysis) ▪ LVHN policy had been that any patient (donor or recipient) scheduled for a procedure required a COVID-19 test within 48 hours. This policy recently changed to 5 days. ▪ Pre op labs now must be completed a minimum of 14 days prior to surgery to ensure serology results are available. Transplant Surgery

▪ Deceased donor surgeries have gone on without major impact. • March-June, 2019: 38 transplants • March-June, 2020: 45 transplants ▪ Every patient gets tested for COVID-19 upon arrival to the hospital. ▪ None of our newly transplanted patients have contracted COVID-19 Transplant Surgery

▪ We resumed living donor surgeries when COVID testing was more readily available ▪ All delayed surgeries were completed by 5/30/2020 • We delayed 2 KPD (paired donations) and 2 directed donations for a total of 7 transplants ▪ Living donor surgeries were comparable but slightly down from last year: • Jan-June, 2019: 12 LD transplants • Jan-June, 2020: 9 LD transplants Visitors

▪ A challenge for patients and families through this time has been that initially there were no visitors allowed in the hospital. ▪ Now, the visitor policy is one visitor per day (can be a different person each day). Virtual Visits

▪ In March, we transitioned to seeing patients of all types virtually (video and phone). ▪ Our typical post-transplant protocol is two appointments per week for two weeks. We currently are doing one office visit and one virtual visit, at MD discretion. ▪ We have also adjusted our in-office schedule to decrease the overlap of patient contact in the office/waiting room. Virtual Visits

Encounters % Digital Encounters % Face to Face Encounters 1,683 19.1% 80.9%

COVID Impact on Transplantation Our Center Experience

Kim Barnett, MSN, MBA-HC, RN CCTC Rebecca Brown MSN, RN, CCTC UPMC Pinnacle@ Harrisburg Hospital 37 Referrals

• Referral process has not changed. • Continue to receive referrals from dialysis and nephrology offices. • Our program has not experienced any significant changes in our referral volumes related to COVID.

38 Transplant Education

• Education process changed quickly! • Our initial response to COVID was to cancel all scheduled pre transplant appointments until we were able to make accommodations for our patient needs and our new staffing plan. • Utilized MS Teams for virtual education appointments.

39 Transplant Evaluations

• Our IT department did a great job of making telemedicine appointments a reality in a very short time frame. • April and May – RN and MD appointments occurred via EPIC telemedicine – SW evaluations via Teams platform – Financial evals via phone • June to present – All evaluation appointments are in person

40 Transplant Evaluations • Initially, our hospital cancelled all “non- urgent” medical testing which delayed our “referral to decision” times for a few weeks. • Currently there are no restrictions on diagnostic or lab testing

41 Transplant Process Changes

• Our initial response to COVID was to stop doing all transplants until we were certain that we were minimizing COVID risks as much as possible. • Suspended our program for 8 days and gradually reactivated patients, starting with lowest risk patients first and then expanding to activate our entire list within a few weeks.

42 Living Donor Transplants

• March and April – To ensure safety for our living kidney donors, we cancelled all living donor transplants for 3 weeks. – Inactivated all our patients in KPD registries during that 3 week period. • May to present – No restrictions on living donor transplants – COVID testing on all living donors and recipients as part of pre op testing

43 Transplant Process Changes in the Hospital • Many changes made for in hospital care – Ensure transplant patients have complete separation from COVID patients and caregivers. – Restricted visitation policies created “opportunities” to do virtual education with patients and family – LOS increased due to need to give infusions during hospital stay vs our usual outpatient process

44 What we learned… • Some patients don’t want anything to do with “virtual care”. • Some patients love “virtual care” and we are continuing to offer virtual education options. • Telemed visits are a great option for stable post transplant patients, but evaluation appointments work better in person!

45 What we already knew….

• Things change EVERY DAY—faster with COVID!! • Reinforced that we are a great team—everyone from administration, IT, hospital staff, (and the list goes on) worked together to provide great patient care.

46 Ways to support patients during the evaluation process • Encourage patients to explore transplantation--we have options to accommodate patient individual needs. • Reinforce that virtual connections are pretty easy to navigate. • Help patients with any technology issues. • Facilitate communication with the transplant staff— we often don’t know patients have concerns—they are more comfortable with their dialysis providers.

47 Referral & Evaluation Procedure During the COVID-19 Pandemic

Cara Morasco

9/25/2020 49 MAIN LINE HEALTH OVERVIEW—ABOUT US

FY19 Data 50 MAIN LINE HEALTH OVERVIEW—MISSION, VISION AND VALUES 51

Transplant Referral Process

• Has not changed during the COVID-19 pandemic – Patients can call (484) 476-8485 – Directly connected to the pre-transplant assistant – Appointments available within 2 weeks – Medical records collected prior to the appointment 52

Transplant Evaluation Process

• Patients present to Lankenau Medical Center for evaluation

• No support people allowed to accompany patients unless it is medically necessary

• Patients will see the multidisciplinary team and complete required labs, tests and consults

• Telemedicine appointments are available for patients unable to travel to LMC Jefferson Transplant Institute Transplant During COVID-19 Pandemic

Joanne Weill-Greenberg, MSS, LSW Transplant Social Worker Telehealth

 We swiftly converted in-person transplant evaluations, live donor evaluations and post-transplant follow-up appointments to telehealth to continue to care for our patients in the midst of the COVID crisis.

 We continue to see 30% of our pre and post-transplant patients via telehealth and ensure to adhere to defined ratio of in-person to telehealth appointments to maintain social distancing and adequate time for exam room disinfection between visits.

 Transplant evaluations are being done via telehealth and in person. Clinic Precautions (Pre and Post-Transplant) For In-Person Appointments:  All patients and support persons are screened the day prior to his/her appointment. If the patient and/or support person screens positive for COVID symptoms or to having been in contact with a person who is known or suspected of having COVID, his/her appointment is converted to telehealth.  We have defined ratios of in-person and telehealth appointments to ensure appropriate time for disinfecting exam rooms and adherence to social distancing guidelines for patients and staff.  We have implemented direct rooming to exam rooms to eliminate patients sitting in the waiting room.  We have instituted policies for appropriate personal protective equipment including face shields and masks for all staff members and masks for all patients and support persons while in the clinic. Testing:

• All deceased donor recipients who are called in for transplant are tested prior to surgery.

• All living donor and recipients of live donor transplants are tested during pre-admission testing at 14 days prior to the case date and within 48 hours of the scheduled surgery. Inpatient Unit:

We have a dedicated inpatient unit for transplant recipients and live donors, which minimizes the chance of exposure to COVID+ patients and ensures a consistent care team of transplant surgeons, nephrologists, nurses, pharmacists and dietitians. COVID+ Patient Monitoring:

• Post-transplant patients who are COVID+ are managed closely by the transplant team. Their labs are drawn at home and they are seen via telehealth.

• They are not seen in clinic until at least 20 days have passed since symptom onset, at least 24 hours have passed since resolution of fever without the use of fever-reducing medications and other symptoms have improved.

OVERVIEW OF THE PROGRAM

• Inclusive program • Dual organ • Kidney, pancreas, liver, heart, lung • Patients encouraged to return to primary nephrologist within 6 months post transplant • HIV transplants • Bloodless transplantation • HCV + (NAT and ab) to non HCV

60 SELECTION CRITERIA

• BMI 40 but depends on patient morphology • Age: 75 but some exceptions for patient physiology • Smoking cessation not mandatory • Certain “drugs” not prohibited • Re-transplants accepted • Complicated medical histories evaluated

61 ADVANTAGES

• Steroid free • Lower induction therapy • Participate in kidney exchange • Living donors with true laparoscopic nephrectomy • Pancreas (and kidney) for type I and type 2

62 CURRENT EVALUATION PROCESS

• Once referral is received patient contacted and scheduled for virtual screening and kidney transplant class • Patient scheduled for virtual meeting with pharmacist, dietician, nurse and social worker • Testing to be completed at Northeastern or local hospital • ECHO, CAT Scan, X-ray, EKG, lab work, & vascular studies (all done in 1 day) • Stress test can be completed at TUH or local hospital (stress to be completed at Northeastern soon) • Surgeon/ Nephrologist visit- can usually be done virtually

63 CONTACT FOR NEW REFERRALS

LIZ LOWRY CELL: 267-788-0566 EMAIL: [email protected] FAX: 215-707-8894

64 Transplant Waiting List Quality Improvement Activity Transplant Wait listing QIA Performance 1,000 900 867 800

700 683 600 500 400

# # InitiationsHome 300 200 100 0 JAN FEB MAR APR MAY JUN JUL AUG Performance Month

OY4 Performance Goal Transplant QIA Performance

# of Patients added to the Kidney Transplant Waiting List each Month

First Time WL Multi Listed WL

97 88 78 75 72 63 60

46

15 17 16 15 13 12 7 9

Jan Feb Mar Apr May Jun Jul Aug Sep Transplant QIA - Barriers

Transplant Waitlist Barriers Reported by QIA Facilities

Patients lack of Follow up with Appointments

Burdensome Transplant Process

Other

Educational Knowledge Gap

Communications Barriers with Transplant Centers

No Adequate Insurance Barrier Categories Barrier Providers lack of Follow up with Patients in the Evaluation Process

0 50 100 150 200 Number of Facility Responses n=327 QIA Interventions – Network 4 Patient Advocate Program Q&A Quality Insights Renal Network 4

Kou Kha-Moua, Quality Improvement Director [email protected] (610) 265-2418, ext. 2820