DEC 15, 1992

Beginning October 1, 1992, the Office of Health Programs (OHP) will maintain a formal Organ Transplant Registry for all Indian Health Service (IHS) eligible patients who are referred for possible transplantation of heart, liver, or bone marrow.

Organ transplants are the single most expensive item for which we expend contract health services (CHS) funds.  For a number of reasons, accurate information concerning the referral and payment for major organ transplant procedures has not been readily available.  The Registry will provide centralized data that will allow for improved monitoring and planning.

Effective January 1, 1993, it will be required that all patients referred for a pre-transplant evaluation or for transplant surgery of the heart, liver, or bone marrow have a Transplant Registry Form completed.  All IHS eligible patients, retroactive to October 1, 1992, should be registered, regardless of the source of payment.  The instructions and process are detailed on the back of the form.

It will be the responsibility of the clinical director of each service unit to communicate with local or Area CHS staff to ensure this process is functional, and that the information submitted is accurate.  The required data should be routed to the Area CHS Officer, who will be the lead OHP contact.

Questions regarding the Transplant Registry should be directed to Stephen W. Heath, M.D., M.P.H., Risk Management Director/Medical Consultant, OHP, on (301) 443-3024.

Attachment

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INSTRUCTIONS

General: This form is to be used for all IHS patients referred for HEART, LIVER, or BONE MARROW transplant evaluations, transplant procedures, or to provide follow-up information, whether or not the IHS is responsible for payment.  Please submit a separate form for each patient at the time of pre- transplant evaluation, within 2 weeks post transplant, at 6 months and one year post transplant, and when payment Information becomes available.  Fill in as much information as possible.  The REGISTRATION NUMBER will be assigned by Headquarters.  PRINT or TYPE all entries.

1 & 2.  Fill in the Patient?s service unit and IHS Area.

3.  Fill in the date the form was completed.

4.  Fill in name of the Area CHSO or other contact person who is filling out the form.

5 & 6.  Give the full name and SSN (if known) of the patient.

7.  Patient's date of birth.

8.  Male (M) or Female (F).

9.  Fill in the complete diagnosis from the medical record or referral form.

10.  If the patient has an alternate resource, circle the appropriate category.

11.  Name the physician or facility that actually referred the patient to the transplant center.  If the patient was sent from a private hospital or physician, so state.

12.  Circle which transplant is being referred for.  If another major organ transplant is being performed, name the organ.  DO NOT use form for KIDNEY transplants.

13.  Fill in this Section if the patient is being referred only for a pre-transplant evaluation.  Fill in the name of the facility and the date of the evaluation.  Indicate whether or not the facility is a Center of Excellence (leave this blank if form is being used prior to the Center of Excellence contract being awarded).  If the facility is not a Center of Excellence, indicate whether or not a contract exists with the facility.

14.  Fill in this section if the patient is being referred for a transplant.  Fill in the name of the facility and the date of the transfer.  Fill in the date of transplant, if known.  Indicate whether or not the facility is a Center of Excellence (leave this blank if form is being used prior to the Center of Excellence contract being awarded).  If the facility is not a Center of Excellence, indicate whether or not a contract exists with the facility.

15.  Fill in as much cost information that is known.  Leave lines blank if the cost data is unknown.  Submit a supplemental form when the information becomes available.  If IHS is expected to be the Predominant payor, fill in anticipated costs.  If anticipated costs are not known, indicate if IHS will be paying "billed chares", "percent of billed charges", "medicare rates", etc.  Complete the Actual Costs column when information is available.  If alternate resources pay, try to obtain the amount paid.  Designate the predominant payor(s) (e.g., IHS, Medicare, etc.) for each category.

16.  Give status of patient at time form is filled out. If the form is being used only to provide an update on the patients status, and previous detailed information has been submitted, you only need to fill in Sections 1-8 and Sections 15-16.

17.  Check the box that indicates the reason for submitting the form (to provide patient evaluation, post transplant, or cost information).

Comments or explanatory remarks may be submitted on a separate piece of paper.

For questions, call the Office of Health Programs (301) 443-3024. FAX completed forms to (301) 227-6213, or mail to Office of Health Programs, Parklawn Building, Room 6A-55, 5600 Fishers Lane, Rockville, MD, 20857.

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IHS TRANSPLANT REGISTRY -- HEART/LIVER/BONE MARROW
(See Instructions on back)

1. SERVICE UNIT __________________________________
2. AREA______________________________
3. DATE___________________________
4. CONTACT PERSON___________________________________
5. PATIENT NAME_____________________________________
6. SSN_____________________________
7. DATE OF BIRTH_________________
8. SEX ______________________
9. DIAGNOSIS: PRIMARY ___________________________________________
   SECONDARY_______________________________________________
10. ALTERNATE RESOURCES: MEDICARE, MEDICAID, PRIVATE, OTHER_______________________________
11. REFERRING PHYSICIAN/FACILITY:_________________________________________________________
12. TYPE OF TRANSPLANT: HEART LIVER BONE MARROW OTHER_____________________________________
13. REFERRING FOR EVALUATION:

    NAME OF REFERRAL CENTER ___________________
    DATE OF EVALUATION__________________
    CENTER OF EXCELLENCE: ___ YES ___ NO
    IF NO GIVE REASON_________________________________________________________
    CONTRACT FACILITY: ___ YES ___ NO

14. REFERRED FOR TRANSPLANT:

    NAME OF REFERRAL CENTER ___________________
    TRANSFER DATE __________________  TRANSPLANT DATE:__________________
    CENTER OF EXCELLENCE: ___ YES ___ NO
    IF NO GIVE REASON_________________________________________________________
    CONTRACT FACILITY: ___ YES ___ NO

15. COST INFORMATION, IF KNOWN:

    	Anticipated Costs	Actual Costs	Payor
    EVALUATION
    ORGAN PROCUREMENT
    TRANSPLANT
    FOLLOW-UP
    TOTAL

16. PATIENT STATUS:

___ALIVE	DATE_______
___DIED PRE-TRANSPLANT	DATE AND CAUSE OF DEATH _______________
___DIED	DATE AND CAUSE OF DEATH ______________

17. REASON FOR SUBMITTING FORM:

___EVALUATION  ___2 WEEKS POST  ___6 MONTHS POST  1 YEAR POST  ___COST UPDATE