Life Plan- Plan of Care

It is our mission that patients, their families, and caregivers have the opportunity to collaborate in their Plan of Care meetings as valued members of their interdisciplinary team (IDT). This involvement provides them the opportunity to share their personal experiences, values, preferences and life goals. Doing so ensures that their voices are heard and their insight is used to formulate interventions that will benefit their individualized quality of care. 

Let’s refocus on:

  • The real value of the Plan of Care

  • Helping patients better understand and participate in their care planning 

  • Assisting facilities to revitalize integration of patients in care planning


Step 1

All members of the facility’s interdisciplinary team must watch the following “Life Plan – Plan of Care” Program Kick Off video. Following on the next page after watching the video, you will be asked to attest to having watched it.

PlayButton-01-1Life Plan, Plan of Care Program: Video Attestation


Step 2

Use the following My Dialysis tools to align dialysis care with patient-identified priorities, promote care individualization, and improve the care planning experience.

My-Dialysis-Plan_Program-Overview_Page_1                             My-Dialysis-Plan-Patient-Brochure-WEB_Page_01                          My-Dialysis-Plan-Care-Team-Guide-WEB_Page_01                    My-Dialysis-Plan-Use-Cases_Page_1

Program Overview          Patient Brochure           Care Team Guide         Use Cases

(English/Spanish)              (English/Spanish)           (English/Spanish)         (English/Spanish)


Pre-Meeting-Patient-Questionnaire                      My-Dialysis-Plan-Care-Plan-Meeting-Sample-Scripts_Page_1                      My-Dialysis-Plan-Care-Plan_English_Page_1

Meeting Logistics          Meeting Scripts             Care Plan

(English/Spanish)           (English/Spanish)           (English/Spanish)


Step 3

All members of the facility’s interdisciplinary team must watch the following “How to” video and attest to having watched it by clicking SUBMIT at end of the page (within the same page where the video is found). The QR Code will lead you to the video/attestation page.

Below you will also find the My Dialysis Plan Tracker & Quarterly Report links. Use the My Dialysis Tracker to gather monthly data for implementation of the My Dialysis tool and plans of care. Reporting links and QR codes are found in the same page as the tracker. Instructions are provided in the “How to” video.

ImproveHealthSafety-01-2                                                                                                                                                                                                QR-code-for-MyDialysisPlan-1

My Dialysis Plan Tracker and Reporting Links               



"How To" Instructional Video: My Dialysis Plan Monthly Tracking and Completing the Quarterly Report

Supportive Resources