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Immigrant Kidney Project: connecting undocumented dialysis patients with more compassionate and cost-effective quality outpatient care

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Immigrant Kidney Project: connecting undocumented dialysis patients with more compassionate and cost-effective quality outpatient care

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Immigrant Kidney Project
Connecting Undocumented Dialysis Patients with
More Compassionate and Cost-Effective Quality Outpatient Care

Ian Farwell, DSW Candidate, LCSW, MSSW, MSG
University of Southern California
Suzanne Dworak-Peck School of Social Work
Doctorate of Social Work Program
March 30, 2019

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Acknowledgments
The Immigrant Kidney Project (IKP) proposal, and the doctoral research underlying,
could not have been completed without a great deal of academic, professional, and familial
support. First, the support of the DSW program faculty was instrumental in my success within
the DSW program, and I am forever grateful for all they have done for me. My advisor, Olivia
Celis, was by my side through the entire process, and I owe her a debt of gratitude for always
being honest and encouraging me to push my project further. Additionally, to the professors and
lectures in the DSW program, I extend deep appreciation for the time and vast amounts of
knowledge shared with me during the development of the IKP. Your insights will serve as a
personal and professional crucible for the rest of my life. Outside of USC, I would like to extend
appreciation to Dr. Rajeev Raghaven, who not only produced the foundational research that
sparked my inquiry into the IKP but also worked with me in identifying local stakeholders in
Texas that were able to help further guide the project and provide real-world perspectives that
were invaluable.
I also want to express my gratitude to Satellite Healthcare, my employer and home away
from home, which has made my doctoral studies both a possibility and reality by allowing me
time and financial support. I must also acknowledge the thousands of undocumented dialysis
patients, who are vital members of our communities, who often continue to live every day with a
lack of adequate care.
Outside of the profession, my family has been a support system for me through all my
academic endeavors, and I appreciate their support and patience through the process. Lastly, and
most importantly, I would like to thank my partner and fellow social worker Anita for everything
she has ever done for me throughout half our lives together. Allowing me to follow my dream of
completing my doctorate meant a great sacrifice on her part, and I will never forget how much
she cared and put herself second to allow for my continued growth. Lastly, our amazing
daughter Arkaydia came into our lives during the course of the program, and she is a reflection
of all that is Anita and all that is us. I love you Anita and Arkaydia with all that I am and all that
I can be.
“If ever there was someone to keep me at home, it would be you” – Eddie Vedder
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Abstract
Recent healthcare reform efforts in the United States have largely focused on controlling
or reducing cost while also improving or increasing quality of care, with cost and quality being
two organizational measures of success that traditionally inefficiently rise in tandem (Friedman,
2016; Orszag & Emanuel, 2010). As the US Healthcare system evolves along lines emphasizing
efficiency, a pivotal area of consideration is the vast array of untapped social determinants of
health and the mosaic of intersecting psychosocial issues that affect that larger Grand Challenge
of creating a healthcare system that is equally accessible to everyone (Walters, et al., 2016).
Toward this end, one area of concern is the high mortality risk associated with being
undocumented on dialysis in many parts of the United States, such as Texas (Cervantes, et al.,
2018; Raghavan, 2017). Not only is such inequity morally concerning, but of significant
financial concern at a time when the cost of care is the highest priority (Fernández & Rodriguez,
2017). With a lack of policy resolution in many parts of the country, calls for programming that
addresses the lack of quality care and elevated financial costs for undocumented patients on
dialysis appears warranted (Raghavan, 2017). In an effort to answer the call for programming to
address said issue, the Immigrant Kidney Project (IKP) has been designed as an innovative new
program that seeks to subvert such harmful social norms by increasing equal access to outpatient
dialysis care while simultaneously reducing the cost to the state and depressurizing local acute
care hospitals. The Immigrant Kidney Project further offers a unique and pragmatic opportunity
to address both a significant moral and financial issue within our healthcare system.

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Table of Contents
Acknowledgments............................................................................................................................2
Abstract............................................................................................................................................3
I) Introduction and Literature Review.............................................................................................5
II) Grand Challenge Selection Narrative.........................................................................................9
III) Problem Statement...................................................................................................................10
IV) Program & Implementation Strategy......................................................................................12
V) Logic Model..............................................................................................................................12
VI) EPIS Framework.....................................................................................................................12
VII) Measure of Process and Outcomes........................................................................................12
VIII) Monitoring Plan and Evaluation Procedures........................................................................12
IX) Financial Plan, Considerations, and Budget Overview...........................................................13
X) Potential Challenges, Limitations, & Ethical Considerations..................................................23
XI) Sustainability and Scalability Overview.................................................................................25
XII) Strategic Communication Plan..............................................................................................27
XIII) Capstone Summary...............................................................................................................31
XIV) References............................................................................................................................32
XV) Addendums & Business Plan Artifact (Addendum 5)...........................................................41
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I) Introduction & Literature Review
“The term ‘globalization’ is most simply used to refer to a process of increasing
interconnectedness among societies such that events in one part of the world increasingly have
effects on peoples and societies far away” (Baylis, Owens, & Smith, 2017). It appears that, in
the 21
st
century, the world is becoming significantly more interconnected in many ways that
range from economic interconnectedness to regional migration and diversity. Researchers also
suggest that "nation states that once contained distinct groups of people based on common
heritage, language, religion, or ethnicity..." are increasingly becoming more diverse and that
"mass migrations are becoming more frequent" "(and are expected to occur more often in the
future)" as a result of "resource depletion" and environmental changes (Phillips, 2016). Thus,
previous systems, which may have once thrived in a more simplistic and homogenous
environment, now have to adapt to a more interconnected system that seemingly has become
more complexly entropic and dynamic over time. An example of such an increasingly large and
complex system is the dialysis system in the United States (US), which includes more recent
intersections with the United States Immigration system and is embedded within an even more
complex larger healthcare system (which includes complex peripheral payer and provider
systems) in the United States. Much of the complexity between said systems appears to have
unfolded largely within the last 50 years, with both the immigration and dialysis systems in the
US having undergone significant changes starting during the 1960-70s (Rodriguez,
2010)(Massey & Pren, 2012). It is important to understand each system independently, and also
how their increasingly more complex intersections affect outcomes for undocumented dialysis
patients, because thousands of undocumented dialysis patients in the US face discrimination that
can lead to a lack of compassionate outpatient care that has a direct effect on patient mortality
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outcomes and also costs the government and hospital systems millions of dollars every year in
inefficient programming (Raghaven, 2017)(Cervantes, et al., 2017).
To begin, it is important to first explore the history of immigration in the US, followed by
a review of the US dialysis system. Discussion will start with immigration, given the fact that
the US immigration system is much older than the US dialysis system and researchers have
indicated that “the empirical literature examining the relationship between history and current
economic development has developed considerably” and “the main fact established by the
literature is that history matters... on long-term economic development” (Nunn, 2009). In other
words, the current state of the US dialysis system has seemingly been affected by and developed
with the context of being embedded within the longer-standing US immigration system, which
has directly shaped challenges faced by undocumented dialysis patients today.
The American Immigration Council and the Immigration Policy Center provided one
source of information that helps illuminate a historical perspective around how US immigration
has unfolded over time (Ewing, 2012). The United States Immigration System has undergone a
long and complex history. According to historical research, there appear to be many different
eras in US history affecting public perception and immigration policy in the US (Ewing, 2012).
According to Dr Walter Ewing, “Senior Researcher at the American Immigration Council,” the
US approach to immigration has had an extreme range from “unrestricted immigration” during
the period between “1492” until “1874” to later a “rise of immigration control and limiting of
immigrants’ rights” following “1986” with the passage of the “Immigration and Control Act of
1986 (IRCA)” and the “linking of immigration control to National Security” seen in a post 9/11
world following the September 2001 World Trade Center events (Donato, Durand, & Massey,
1992)(Ewing, 2017)(Ewing, 2012). Starting a historical review with the first North American
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immigrants, Dr Ewing indicated that “technically, the first immigrants (to what is now the US)
arrived from Asia between 12,000 and 30,000 years ago by crossing the Bearing Strait” but that
“the first permanent European settlement... was established by Spain in 1565,” and that
“throughout the colonial era, there was no centralized regulation of immigration” (Ewing 2012).
And, he goes on further to indicate that the “first federal law devoted explicitly and exclusively
to immigration was the Steerage Act of 1819, which established continual reporting of
immigration to the US” via “passenger manifests of all arriving ships” (Ewing, 2012). Since
1819, much has changed with regard to immigration regulation, policy, and law, and Ewing goes
on further to describe a system emerging during the later parts of the 20
th
century and early 21
st

century that includes historical discrimination based on race, disability, and nation of origin that
has affected the “Chinese,” “Japanese,” “Mexican” and other cultures disproportionally (Ewing,
2012). From this research, it appears clear that many groups in the US have faced immigration-
related discrimination. However, for the purpose of this review, Hispanic and Latino
immigration will be looked at more closely as it relates to dialysis and lack of outpatient care.
Topic experts state, “America is built upon a history of immigration; yet current
immigration policy and anti-immigrant sentiment negatively affects the vulnerable population of
immigrant families and children” (Androff, et al., 2011)(Sherman, et al., 2013)(Massey & Pren,
2012). Moreover, other researchers have indicated that there is a “need for a new narrative in the
U.S. immigration system” (Keyes, 2011). To add credence to the charge for a “new narrative,”
another collaboration between University of California Berkeley and Yale found that “personal
economic circumstances play little role in opinion formation, but beliefs about the state of the
national economy, anxiety over taxes, and generalized feelings about Hispanics and Asians, the
major immigrants groups, are significant determinants of restrictionist sentiment” toward
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immigrants (Citrin, et al., 1997). Furthermore, subject matter experts report the “rising illegality
(related to US immigration) is critical to understanding the disadvantaged status of Latinos
today” (Massey & Pren, 2012). Researchers further indicate that the issue has become
increasingly more political and complex, as the Latino Population in the US has grown from
"4.7% of the U.S. population" to "16.3%" "over the last four decades" (Massey & Pren, 2012).
One area that appears to be affected by a move toward more “restrictionist sentiment” is
the dialysis services industry (Citrin, et al., 1997). Dialysis services, relative to the long history
of immigration policy in the US, has undergone a much more brief history given the first dialysis
patient was treated for “chronic renal failure by repeated hemodialysis” in only “March 1960”
(Blagg, 2007). Moreover, it was not until 12 years later that "in 1972, Congress passed Public
Law 92-603 amendment to the Social Security Act, extending ESRD (End Stage Renal Disease)
coverage to all individuals who had worked long enough to qualify for Social Security Benefits"
(Raghaven, 2017). However, “undocumented individuals, even those who may have contributed
to social security, (were) excluded from this coverage” (Raghaven, 2017). The lack of coverage
of undocumented patients is not necessarily surprising, given the previous research that indicates
that restrictionist immigration sentiment was on the rise in the US during the period following
the advent and expansion of dialysis services in the US. However, even though undocumented
dialysis patients in the US often cannot receive outpatient dialysis services, an "Amendment
1867: Emergency Medical Treatment and Active Labor Act (EMTALA)" in "1986" helped to
ensure that undocumented patients at least receive dialysis services in emergency rooms settings,
despite the lack of coverage in outpatient settings (Raghaven, 2017). This is an important
distinction, because researchers suggest that treating patients in only the ER setting is not only
costly but also less compassionate than an outpatient setting, and the “Renal Physicians
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Association Position Statement on undocumented immigrants and dialysis... states that ‘The
federal government has an ethical and fiscal responsibility to provide care for patients within our
borders” (Cervantes, 2017)(Fernandez & Rodriguez, 2017). The issues facing undocumented
dialysis patients, and a lack of outpatient dialysis services in the US, continues to this day
through many parts of the US, which directly affects undocumented Latino patients in great
numbers (estimated at 6,480)(Cervantes, et al., 2017). This is where the harmful social norm,
within a history dynamic, has emerged where exclusive policy and anti-immigrant behavior has
become the norm in the US following 9/11. Thus, further investigation and review is warranted
into what can be done to address the issues faced by undocumented immigrants who are
restricted from more compassionate and less expensive outpatient dialysis care.
II) Grand Challenge Selection Narrative
“Despite increased attention, our health system has made insufficient progress in
reducing” “dramatic health inequalities in the United States that exist by” “race, ethnicity...”
“disability status, geography...” “and, socioeconomic status"(Walters, 2016). Furthermore,
researchers find that "too little attention has focused on the social determinants of health” posing
a “Grand Challenge” in “Health Equity” (Walters, 2016). One such social determinant is
immigration status, which is at the intersection of disability status, socioeconomic status, and
geography. Specifically, the lack of outpatient dialysis care provided to undocumented
immigrants in many parts of the US is of significant concern, and places unnecessary financial
strain on the healthcare system which provides an opportunity for interventions that correct
inequality resulting from such social determinants (Cervantes, 2017; Raghaven, 2017; Fernandez
& Rodriguez, 2017; Kuruvilla & Raghaven, 2014). Working to address this issue will, not only
help a marginalized and vulnerable population of our fellow community members, but also work
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toward chipping away at the larger issue of Health Inequality in the US by ensuring that all
people regardless of geographic origin have access to the same high-quality healthcare. Lastly,
not only will the proposed intervention that follows address the underlying moral issue of a lack
of equity-based healthcare in the US, but also dramatically reduce the overall cost of providing
care to patients receiving dialysis care in the US which embeds within the larger US healthcare
narrative that is trending toward overall cost containment while improving quality. Toward this
end, the following Immigrant Kidney Project (IKP) seeks to be the leading empirically-based
answer to the charge of addressing the Grand Challenge of creating a more equitable healthcare
system by providing equally adequate dialysis care to all patients suffering from End Stage Renal
Disease (ESRD) in the United States (Raghaven, 2017)(Walters, 2016).
III) Problem Statement

A gap in health outcomes for undocumented immigrants exists in the United States, and
transcends across a great many disease processes and intervention options (Fernandez &
Rodriguez, 2017; Gray, Boucher, Kuchibhatla, Johnson, 2017; Gittler, et al., 2017; Raghaven,
2017; Hamel, et al., 2014; Itens, Jacobs, Lahiff, & Fernandez, 2014). Moreover, the American
Academy of Social Work and Social Welfare (AASWSW) has tasked society with the goal of
“eradicating” such “health inequalities for future generations” (Walters, 2016). Specifically,
research has been conducted into the well-documented poor and unequal physical and behavioral
health-outcomes that many undocumented dialysis patients living with End Stage Renal Disease
(ESRD) face in many parts of the country, with considerable attention paid to Texas which has
the second largest number of overall undocumented immigrants in the US and with the highest
rate (“75%”) of uninsured undocumented immigrants (Cervantes, 2018; Cervantes, et al., 2017;
Kuruvilla & Raghavan, 2014; Raghaven, 2017; Raghaven, 2012; Rodriguez, 2010). Moreover, it
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has been found that undocumented dialysis patients in many part of the US, such as Texas, are
often denied insurance coverage (and therefore essentially denied access) for higher quality more
compassionate outpatient care than documented individuals gain almost automatically by virtue
of being a resident or citizen when diagnosed with ESRD (Raghaven, 2017; Sheikh-Hamad, et
al., 2007). In an attempt to address the undocumented dialysis patient health gap, a program
coined the Immigrant Kidney Project (IKP) has been designed to help close the gap and improve
care for such undocumented dialysis patients, starting in San Antonio, Texas. The IKP program
is first of its kind and seeks to partner with local hospitals as a stand-alone 501c3 non-profit
organization in Texas by providing education, support, and linkages for patients to commercial
insurance using research-backed interventions (Raghaven, 2017).
Despite the clinical benefits of connecting undocumented dialysis patients with outpatient
services, it appears that the real barriers preventing undocumented dialysis patients from
accessing high-quality outpatient care are laws and regulations that do not allow for the
extension of most major forms of health insurance to undocumented immigrants in the US
(Rodriguez, 2010). However, new research has provided a complex workaround that takes
advantage of what appears to be a loophole that can first connect undocumented dialysis patients
with commercial health coverage and then subsequently help them find additional charitable
funding to help mitigate the cost of such plans (Raghaven, 2017). This new programming may
serve as a major breakthrough facilitator. Additionally, another major facilitator to increased
funder-interest is that utilizing such plans can help save millions in wasteful spending on lower
quality emergency-based care and help improve undocumented dialysis patient health outcomes
(Hurley, et al., 2009). However, the same research has concluded that even though the discovery
of this intervention was “first described” in “2014,” the intervention is still “neither widely
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publicized nor utilized” (Raghaven, 2017). It remains unclear why it has been so difficult to
disseminate such interventions, and some potential cause or barriers could range from lack of
awareness of the issue to anti-immigrant xenophobia leading to a lack of willingness to create
programming for this population (Grupta & Fenvez, 2017; Traverso, 2017; Martinez, et al.,
2015). Nonetheless, the challenge of disseminating said research-supported intervention remains
significantly incomplete, yet necessary.
Moving forward, a detailed business plan, which includes a program strategy, logic
model, implementation framework, measurement details, and a plan for monitoring the
implementation process has been developed (See Addendum 5) to help guide the IKP in its
development toward meeting its mission of improving the quality of life and health outcomes for
undocumented dialysis patients and their families.
IV) Program & Implementation Strategy
See Addendum 5: IKP Business Plan – Section 8.1
V) Logic Model
See Addendum 5: IKP Business Plan – Section 8.2
VI) EPIS Framework
See Addendum 5: IKP Business Plan – Section 8.3
VII) Measure of Process and Outcomes
See Addendum 5: IKP Business Plan – Section 8.4
VIII) Monitoring Plan and Evaluation Procedures
See Addendum 5: IKP Business Plan – Section 8.5

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IX) Financial Plan, Considerations, and Budget Overview
As has been illustrated, a large discriminatory healthcare gap exists between
undocumented immigrants and their access to outpatient dialysis services. The mission of the
proposed program is to help bridge the gap for undocumented immigrants needing outpatient
dialysis services, which is a mission based on the value that all people (regardless of residency
status) living in the US deserve access to cost-effective outpatient dialysis care.
A) Auspice Identification:
Initially, the Immigrant Kidney Project program was conceptualized as being embedded
within an existing outpatient dialysis center, but it appears that there may be potential legal
issues related to remuneration laws preventing such an embedded program because an embedded
program may be viewed as "offering gifts and other inducements to beneficiaries" (Department
of Health & Human Services, 2002). However, despite limitations that may preclude a provider
from being able to directly create such an embedded program, the Office of Inspector General
(OIG) has explained that:
OIG reiterates that nothing in section 1128A(a)(5) prevents an independent entity,
such as a patient advocacy group, from providing free or other valuable services
or remuneration to financially needy beneficiaries, even if the benefits are funded
by providers, so long as the independent entity makes an independent
determination of need and the beneficiary’s receipt of the remuneration does not
depend, directly or indirectly, on the beneficiary’s use of any particular provider.

Therefore, an external non-profit structure will allow the program to be funded directly by a
Large Dialysis Organization (LDO) or other dialysis-related entity (ie. physician group, etc.)
seemingly without penalty under remuneration laws as long as it is external. Therefore, the
program is now conceptualized as an external private 501c3 non-profit patient advocacy group
and under the auspices of the non-profit and Board of Directors.

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B) Internal Stakeholders:

In order for the Immigrant Kidney Project to be successful, a number of internal
stakeholders will need to be involved before and throughout the program implementation. A
general list of internal stakeholders includes the program Executive and Program Director, Board
of Directors, staff Social Worker and Educator, and Manager of Volunteer & Intern Services.
• Executive Director – will be responsible to lead the organization toward its mission of
providing services that help close the gap for undocumented dialysis patients in the US,
and will have full control of budgetary authority under the guidance of the Board of
Directors. Additionally, the Executive Director will be responsible for building new
relationships with hospitals and dialysis providers.
• Board of Directors – will be responsible for ensuring the viability of the organization
until the mission has been fulfilled.
• LCSW Patient & Staff Educator– will keep staff up-to-date on existing healthcare policy
related to the mission of the organization, and will conduct outreach visits to patients
coordinating the connection of undocumented patients with insurance eligibility
resources and subsequent connections with outpatient dialysis units. Provides
supervision to social work interns as needed.
• Administrative Staff – Helps manage office duties, and works with the team to coordinate
internal functions.
• Manager of Volunteer & Intern Services – will be responsible for recruiting and
managing volunteer and social work intern staff, who may assist with office and/or field
work as needed.

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C) External Stakeholders:

Given the complex nature of healthcare, dialysis services, and the immigration system in
the United States, a number of critical external stakeholders have emerged during the design of
the Immigrant Kidney Project.

• Hospital Affiliations – will be the central means by which the Immigrant Kidney Project
group anticipates getting referrals for services. Hospitals, eager to reduce the number of
undocumented dialysis patients they service on an inpatient basis, will provide direct
referrals to the IKP for further assistance.
• Large Dialysis Organizations (LDOs) – Support from the LDOs may be a critical source
of revenue if insufficient funding can be secured from hospitals, government grants, and
other sources. Additionally, LDOs will be able to refer patients whom they are actively
treating, should such patients lose insurance coverage due to immigration-related issues.
• Patients – will play a pivotal role in program success. Undocumented patients and
families will need to be willing to work with staff to address issues related to patient
insurance and/or immigration barriers.
• Nephrologists – will also serve as a potential source for patient referrals, given that many
patients follow a local Nephrologist in the community when they have early forms of
Chronic Kidney Disease (CKD) before it progresses to dialysis-dependent ESRD.
Additionally, Nephrology related donations might serve as a source of revenue.
• National Kidney Foundation (NKF) – is a leading group dedicated to the betterment of
those living with CKD, and has been leading discourse for a number of years on the
issues faced by undocumented members of the renal community. The NKF will likely be
a significant source for further advocacy and greater issue awareness moving forward.
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• Politicians – As has been illustrated, healthcare utilization for undocumented dialysis
patients has intersected with political initiatives, and will likely continue to do so for the
foreseeable future (Zarembo & Gorman, 2008). It will be important to understand
political changes and anticipate potential changes in the needs of patients serviced by the
Immigrant Kidney Project.
• Insurance providers or affiliated groups or organizations may play a pivotal role as an
external shareholder. Although current laws allow for the purchase of commercial
insurance policies (which is the centerpiece of the proposed Immigrant Kidney Project
intervention), researchers have presented potential examples of ways that commercial
insurance providers may present opposition and advocacy against proposed interventions
(Raghaven, 2017). It unclear how policy may be affected or change in relation to such
effort from insurance providers, and the Immigrant Kidney Project may need to be
adaptable to such change.
• Additionally, hospital and LDO providers may also present a barrier if unwilling to work
and advocate for the needs of undocumented patients. Attitudes that may negatively
affect successful Immigrant Kidney Project implementation can range from ambivalence
to outright hostility toward undocumented immigrant ESRD patients, which could
present a barrier if undeterred (See Ethical concerns section for further review).

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D) Revenue Streams:

In order for the Immigrant Kidney Project to be successful, a number of revenue streams
will likely be needed to cover all costs associated with delivering necessary services to
undocumented dialysis patients in Texas.
• Hospital-Based Funding – Primary revenue streams will include local hospital support.
Hospitals have arguably the most to gain from reducing the number of inpatient
undocumented immigrant dialysis patients, in that inpatient care is significantly more
costly than outpatient treatment. A relatively small contribution from local hospitals will
likely offset the burdensome cost of inpatient care and ongoing program support.
• Large Dialysis Organization (LDO) Funding – A large source of funding will come from
the LDOs. Although by law, the Immigrant Kidney Project cannot direct patients to an
LDO once they have secured commercial insurance policy coverage, there is an existing
LDO infrastructure in place, that will likely admit a majority of Immigrant Kidney
Project-assisted patients following their time with the program (Department of Health &
Human Services, 2002). For example, the American Kidney Fund (AKF) operates under
similar revenue streams (and similar legal restraints) and receives significant funding
from the LDOs (American Kidney Fund, 2016).
• Small Dialysis Organizations (SDO) Funding – Smaller dialysis providers, both for-profit
and non-profit, will also provide additional support for the organization (which also is in
line with the AKF example provided previously). In some cases, SDOs have provided
more funding than LDOs to similar organizations like the AKF, and should not be
counted out as a significant source of revenue generation (American Kidney Fund:
Annual Report, 2016).
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• Grants – Depending on the level of support provided by the dialysis organizations
mentioned above, it would likely be necessary to secure grant funding to help support the
mission of the organization. Diversifying funding streams will likely provide greater
overall financial security by mitigating year-over-year fluctuations and variance in
funding from dialysis organizations.
• Public Donations – depending on the level of support provided by grants and dialysis
organizations, additional funding would be secured through direct-mail marketing
campaigns targeted toward patients and nephrology groups in the community as a last
option.
Of these potential revenue streams, hospital-based funding will be the cornerstone or central line
of funding. There is a high level of confidence that local hospitals will be persuaded to the
Immigrant Kidney Project initiative, given the overwhelming cost savings to local hospitals. For
example, recently researchers on the issue have pointed to a recent study indicating that the
average cost for undocumented patients to receive hospital-based dialysis care in Houston was
"nearly four times more than those receiving scheduled dialysis: $285,000 versus $77,000 per
year," and that "Medicaid Services classifies such cases (the higher cost of providing care to
undocumented patients cases versus US citizens cases) as "superutilizers" and references another
study indicating that there have years where "3% of superutilizers" in some locations "accounted
for 30% of the total charges" to local hospitals (Raghaven, 2017). Moreover, the cost difference,
between scheduled outpatient dialysis services in Texas versus providing non-scheduled
inpatient hospital-based care to undocumented patients results in a yearly cost savings of
$208,000 per patient per year. Therefore, if the Immigrant Kidney Project were successful in
assisting 50 undocumented ESRD patients to move away from hospital-based care to scheduled
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outpatient dialysis treatment, the total savings to the local hospital and insurance provider for all
50 patients would be a staggering $10.4 million dollars. It goes without saying that developing
an effective program from only $345,000 for year-one, with the potential to yield millions of
dollars in savings, would be a drop-in-bucket for an overall net gain. Additionally, given that
undocumented ESRD patients are barred reimbursement of outpatient services in some regions
of the US, the dialysis providers are potentially losing out on “$77,000” per year per
undocumented patient that never moves beyond hospital-based care, which equates to a $3.85
million dollar loss of potential revenue for local dialysis providers that is not being captured in
the current healthcare environment. Moving beyond primary support from local hospitals and
dialysis providers, the further development of various additional non-hospital and non-dialysis
based funding streams (ie. grants, donations, etc.) would ensure that the Immigrant Kidney
Project does not become beholden to anyone particular funding hospital, and thus additional
forms of revenue would help ensure that the Immigrant Kidney Project as a non-profit can stay
true to its mission, values, and vision of providing non-biased support and referrals to
undocumented patient in need of outpatient dialysis services.

E) Revenue Estimate:
The estimated budget for the first year of operation is $345,000. The initial budget
projections include the cost for office rent, staff salaries, supplies and equipment, and utilities.
As mentioned a mixture of hospital-based funding, LDO, SDO, Grant, and public donations will
be used to fund the program, with the largest emphasis on revenue from hospital-based funding.
The logic for this payer mix is that hospital-based funding is most realistic due to hospitals
having the largest financial incentive and potential gain from the Immigrant Kidney Project.
However, additional funding streams will likely be important to gain additional support for any
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additional financial needs not covered by the hospital-based system, and allow for some
flexibility and allow the program freedom from being absolutely beholden to the hospitals with
whom the program has financial relationships.
F) Budget Allocation Proposal
1) Budget Format and Cycle

The format of the current budget allocation will be in the form of a Line Item Budget,
showing expected revenue and anticipated expenses that the Immigrant Kidney Project will
incur during the Calendar Year January 2020 through December 2020 (See Addendum 5).

2) Revenue Projection
The projected initial annual 2020 start-up budget for the Immigrant Kidney Project
program will be $345,000. To meet the revenue goals, a number of revenue sources were
discussed previously ranging from hospitals-based funding, large and small dialysis service
funding, various grants, and potentially public donations.

3) Phases of Intervention
There are a number of phases that an Immigrant Kidney Project participant would need to
go through in order to benefits from the program. First, participants would need to speak with
local Immigrant Kidney Project outreach workers in the participating hospitals in the language
of choice. Second, follow-up visits with participants and family would likely need to be
conducted outside the hospital following discharge. A trained Masters-level Renal Social
Worker would need to meet with participants and family during these visits to discuss benefits
of outpatient care, benefits of full-scope commercial insurance coverage, risks and rights of the
patient, limitations of Immigrant Kidney Project, additional supporting applications for
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insurance exchanges and American Kidney Fund HIPP program support, and availability of
additional long-term support should participants lose their insurance coverage at future date.
Once a patient undergoes a qualifying life event (QLE) and can enroll in a commercial
insurance policy, the patient may also need further peripheral support as they potentially
transition back through the hospital setting and into an accepting outpatient dialysis unit, which
is where an IKP Social Worker will be available to assist through the process. Once the
participant has been successfully established with a local outpatient dialysis unit for 90 days
(the period where dialysis patients are most vulnerable), the Social Worker can then move to
discontinue IKP services. Participants will have the ability to contact the Immigrant Kidney
Project support program in the future, should they lose insurance coverage or experience other
barriers to long-term outpatient dialysis care. Also, the following intervention model will be
used to conceptualize the proposed intervention (See Addendum 5: IKP Business Plan; Section
8.2.1 Logic Model):
• Input: Trained Social Work Staff and Financial Resources
• Throughput/Activities: Education and Support through the above-mentioned clinical
intervention and outreach
• Output: The number of ESRD patients that move from inpatient hospital-based care,
through the Immigrant Kidney Project, and into outpatient dialysis care for a period of 90
continuous days within one calendar year January 2020 to December 2020.
• Outcome: Patient health improvements, as measured by dialysis lab values, will be
measured. And, the total cost savings to local hospitals will be calculated.
• Impact: Eventually, this model will lead to a significant reduction in the number of
undocumented patients without outpatient dialysis care, and may even eradicate the issue
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entirely. Therefore, a piece of the larger issue of the US Healthcare system disparity will be
eliminated and move one step closer to a system that transcends marginalization associated
with the social determinants of health.
4) Units of Service
As mentioned, the number of ESRD patients that move from inpatient hospital-based
care, through the Immigrant Kidney Project, and into outpatient dialysis care for a period of 90
continuous days within one calendar year January 2020 to December 2020. Subsequent Units
of Service may also include a more macro perspective in the number of hospital-based partners
that can be recruited to provide patient referrals, but initial start-up requirements will be likely
be based on one or two hospital or dialysis partners.
5) Staffing Plans & Costs
Initial staffing plans will include an Executive Director, LCSW & Staff Educator,
Administration Staff, and Manager of Volunteer & Intern Services. Early on in the program
development and implementation, all staff will be critical to the success of the organization.
Guidance and leadership will be pivotal because the Immigrant Kidney Project will be
innovative, new, and one-of-a-kind, and therefore unforeseen hurdles may present that need
leadership due to program novelty. Additionally, dedicated and passionate Social Work staff
will need to not only be trained initially but remain passionate about learning about the system
as it changes in response to programs like Immigrant Kidney Project. And lastly, admins and
volunteer staff will be the central staff component that makes all the day-to-day operations
flow and function seamlessly. Without any one group within the team, the program would
struggle in its infancy.
(See Addendum 5: IKP Business Plan; Section 7.7: Line Item Budget)

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6) Other Spending Plans & Costs
In addition to labor costs, office rent, office supplies, office equipment, utilities, and other
services will be necessary as follows. It will be important that the first office be local to
funding hospitals, as they will simultaneously be the primary funder and referral source for the
first 50 patients during program year one.
(See Addendum 5: IKP Business Plan; Section 7.7: Line Item Budget)
7) Revenue vs. Costs
(See Addendum 5: IKP Business Plan; Section 7.8: Revenue vs. Cost Analysis)

G) Challenges, Constraints, and Complicating Factors
(See Addendum 5: IKP Business Plan; Section 5.1.2 Weaknesses; 5.1.3 Opportunities;
5.1.4 Threats; 5.1.5 Barrier and Facilitator Analysis)

X) Potential Challenges, Limitations, and Ethical Considerations:
Although most major stakeholders seek to gain from the Immigrant Kidney Project, there
is one group that poses the greatest risk. Commercial insurance providers may not be keen to the
idea of having to inherit the burden of paying the cost of outpatient dialysis care. However, it
should also be noted that they will not incur the entire cost of the 3.8 million dollars to provide
dialysis care to undocumented immigrants, as the intervention is contingent upon patients
receiving direct support from the American Kidney Fund's (AKF) Health Insurance Premium
Program (HIPP). Such support would likely offset a significant cost to insurers by paying
healthcare premium payments to the insurance providers. The limitation is that this factor is the
most unpredictable aspect of the program, and care would need to be spent in helping the issue
progress in a meaningful way. However, as the issue stands now, there are protections in the
Affordable Care Act that do not allow insurance companies to deny undocumented patients from
accessing policies based on disease or preexisting conditions (The United States Department of
Farwell 24
Health and Human Services, 2017). Therefore, although insurance companies may provide
resistance there may be limited recourse they have under current law.
Ethical Considerations
Whenever working with a vulnerable and marginalized population, ethical considerations
are of concern. And, there are many such considerations when working with undocumented
participants. In order to ensure that the IKP adherence to a structured ethical framework, the
program will adhere to the Social Work Code of Ethics provided by the National Association of
Social Workers and also ethical guidelines provided by the American Psychological Association
(APA, 2019)(NASW, 2017). Particular emphasis will be placed on participant autonomy,
justice, and benevolence. With regard to justice, the IKP seeks equal access to quality care for
undocumented immigrants. As for autonomy, the IKP seeks to empower participants to better
understand their dialysis healthcare and insurance options within the current healthcare and
dialysis markets, and also be able to utilize such knowledge to gain greater access to better
quality and more compassionate care. Lastly, IKP staff will work tirelessly to ensure that no
harm comes to participants to the fullest extent possible, or mitigate such potential harms
wherever foreseeable and possible.
Within such efforts to ensure that patients receive services that adhere to strict ethical
guidelines, there are a number of areas that present as potential sources of vulnerability for
ethical challenges. One issue relates to the for-profit nature of dialysis more generally. Not all
dialysis organizations are structured as for-profit, but the two largest dialysis organizations
(LDOs) are both structured as for-profit organizations, which may present ethical concerns when
entering into financial relationships with said organizations. In other words, the IKP's funding
Farwell 25
structure is currently contingent upon direct funding from the LDOs, therefore there may be
increased incentive to funnel patients to a particular provider that may not be the most
convenient or preferred choice of the patient. To safeguard against such issues, the IKP has
elected to only receive a limited amount of funding directly from LDO, preferring to receive the
lion's share of funding from the referring hospitals. Such a move should provide enough
financial shelter to ensure that the IKP can continue to refer patients to outpatient dialysis centers
that are the best fit for participants based on a more participant-centered model of service and
care.
Another potential source of ethical concern will be to make sure that participants are not
ill advised about potential insurance options. In other words, there are often different insurance
and care options that will come with pros and cons, rather than a one-size-fits-all perfect
solution. To ensure that participants are not oversold on potential options, IKP field staff and
educators will be trained to provide objective information about options, which will include both
benefits and potential limitations. Staff will also never select insurance plans for participants
directly, but rather help provide objective information and answer questions related to the
participants' potential selection of said insurance plans.
Another issue is regarding post-service follow-up. Once a patient has successfully
initiated treatment with outpatient care, and received adequate insurance coverage to support
such care, the patient will be scheduled for termination of services with the IKP program.
However, issues may arise after services are provided to the patient. Therefore, all IKP
participants will be provided with IKP contact information and follow-up instruction should they
need additional support, services, or education after being discharged from IKP programming.
Farwell 26
Lastly, confidentially will be of the utmost important, and great measures to protect
patient confidentially will be taken. Also, no records will be released to the public or otherwise
with a validated court order.
These have been some of the ethical considerations faced by the IKP, and there may be
more issues that arise once the IKP is operational. Therefore, IKP leadership and field staff will
meet regularly to identify and mitigate future ethical considerations as they arise in the future.
Additionally, laws and public policy affecting the IKP and participants may change in the future
and the IKP leadership will monitor and address such issues as they arise.
XI) Sustainability and Scalability Overview
In its first year, the Immigrant Kidney Project seeks to assist 5% of the population in
Texas. If proven successful, the Immigrant Kidney Project could easily be adapted to assist the
remaining 95% of undocumented dialysis patients in Texas. Later, the program could be
expanded and transported to other states quite easily as the model is universal to the US. Thus,
there is likely much work to be done for many years to come. That is, of course, if current policy
does not change to start providing coverage for undocumented dialysis patients. But, such an
action would solve the greater mission of the organization, which is to end immigrant dialysis-
related discrimination. If this were to occur, the program could easily be morphed into a
program that provides meaningful support and advocacy for the general undocumented patient
population on outpatient dialysis to ensure that other discriminatory practices like lack of access
to kidney transplant are also addressed. (See Addendum 5: IKP Business Plan; Section 4.0
Market Analysis; 4.1 Industry Analysis; 4.2 Market Tests; 4.3 Market Needs, 4.4 Market Trends,
4.5 Market Growth; 4.6 Positioning; and 5.0 Marketing Strategy and implementation).
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XII) Strategic Communication Plan
Strategic Communication Plan
Immigrant Kidney Project

The Immigrant Kidney Project (IKP) has been designed as a 501c3 non-profit organization that
works to help close the health gap for undocumented immigrants living with End Stage Renal
Disease who need ongoing maintenance dialysis in lieu of a kidney transplant to survive.

The IKP in an innovative new solution, which helps lower overall cost while simultaneously
providing more adequate compassionate care, and was born out of the research provided by
experts and leading nephrologists close to the issue. Due to the novel nature of the program, it
will be imperative to mission success to first help bring awareness of not only the issue but also
the benefits of the IKP intervention. Toward this end, of helping communicate the needs of
undocumented dialysis patients and the potential benefits of the IKP, a Strategic Communication
Plan has been developed to help set a structured framework of how the IKP leadership team
plans to help bring great awareness to the issue and program benefits.

Strategic Direction 1: Highest Patient Health Outcomes

Target Audience:

• Large Dialysis Providers
• Local Hospital System Administrators
• Local Nephrology Researchers
• Small Dialysis Providers
• Potential IKP Program Participants
• Current Patients living with ESRD
• The families of patients living with ESRD

Message:

• Helping to connect patients on dialysis with outpatient dialysis related care is the most
compassionate and efficient means to increase overall health outcomes for undocumented
immigrants and help close the health gap for undocumented immigrants in the United
States.

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Media:

• Professional short-form videos highlighting health benefits related to the IKP will be
developed that will be shared with local dialysis providers, potential local community
hospital providers, patients and families, and other members of the local community
struggling with such issues.
• Create a social media presence targeted at local recipient stakeholders.
• Create a direct contact presence, including Yelp and other systems.
• IKP Infographic (See Addendum 1)

Action Steps & Techniques:

• As the current Director of Patient Experience at Satellite Healthcare, the IKP Executive
Director Ian Farwell plans to leverage his current industry connections with small and
large dialysis providers to show short-form videos to garner support for the issue.
• Ian has already been having discussions with current leaders in the field.
• Short-form videos will utilize a number of persuasive techniques, which will include
appeals to logic using research-backed data and support.
• Short-form videos will also utilize appeal to emotion through patient and family
testimonial. The emotional appeal will seek to help motivate dialysis industry leaders
and other stakeholders through a moral argument that providing assistance for fellow
community members is the "right thing" to do.

Strategic Direction 2: Lowest Cost to Financial System

Target Audience:

Primary
• Large Dialysis Providers
• Local Hospital System Administrators
• Local Nephrology Researchers
• Small Dialysis Providers

Secondary
• Potential IKP Program Participants
• Current Patients living with ESRD
• The families of patients living with ESRD

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Message:

• Connecting undocumented patients with outpatient dialysis services helps lower the cost
of providing dialysis services by up to 4x the cost.
• For every 50 patients served by the IKP, local hospitals can save nearly $10 Million in
"superutilizer" spending.
• For every 50 patients served by the IKP, local hospitals can help decongest and
depressurize their Emergency Rooms freeing up space for other healthcare related
challenges.
• For every 50 patients served by the IKP, local dialysis providers can increase revenue by
nearly $4 million dollars of untapped reimbursement through IKP interventions.

Media:

• In-person stakeholder awareness campaign, which will include meetings with local
dialysis leadership, local hospital administrators, and other community stakeholders such
as the National Kidney Foundation, Council of Nephrology Social Workers, Renal
Network agencies, and potential the Department of Health.
• Professional short-form videos highlighting health financial benefits related to the IKP
will be developed that will be shared with local dialysis providers, potential local and
community hospital providers.
• Develop professional brochures and information handouts to be provided to financial
stakeholders.
• Add ongoing information on program developments in community newsletters and other
printed materials.

Action Steps & Techniques:

• As the current Director of Patient Experience at Satellite Healthcare, the IKP Executive
Director Ian Farwell plans to leverage his current industry connections with small and
large dialysis providers to show short-form videos to garner support for the issue.
• Ian has already been having discussions with current leaders in the field.
• Develop short-form videos that will utilize a number of persuasive techniques, which will
include appeals to logic using research-backed data and support.
• Short-form videos will also utilize appeal to emotion through patient and family
testimonial. The emotional appeal will seek to help motivate dialysis industry leaders
and other stakeholders through a moral argument that providing assistance for fellow
community members is the "right thing" to do.
• Leveraging of existing community partnerships will be employed.
• Snowball and leverage financial resources and existing marketing streams of large
dialysis providers that partner with the IKP.
• Speaking events at the National Kidney Foundation.
• Partnering with community Nephrologist partners.
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Communication Plan Conclusion

The Immigrant Kidney Project (IKP) is an innovative new solution to a long-standing
life-threatening community health challenge that needs to be addressed from both a moral and
financial perspective. However, a key barrier remains in communicating the urgency of the
issue, new innovative solutions, the health ramifications of continuing the current course of
inactivity, and potential financial consequences of current wasteful spending. The previous
communication plan has sought to lay the groundwork for communicating such information and
helping to persuade individual stakeholders into active participation on efforts that not only help
their current or future patients but also help their respective organizations from a financial
perspective as well.

Key mechanics of the above-described communication plan will seek to be persuasive
and not engage in manipulation or coercion, and rather seek to partner with community
stakeholders in improving the lives of undocumented dialysis patients while reducing the cost to
the overall health care system in the United States. The ultimate goal will be to help shape
attitudes in the direction of creating a desire to help a desperately in-need patient population
living with renal failure.

Key emotions expressed in the IKP communication plan will include a fear for dialysis
organizations of lost revenue, guilt of allowing fellow community members to suffer and die
when adequate intervention exist at a fraction of the current cost to the system, and help remove
unwanted emotions through providing a positive emotional appeal in that adequate solutions are
available with key support from local stakeholders.

The current communication is likely to succeed in that it directly targets key stakeholders
by leveraging existing direct relationships help by the IKP Executive Director, and utilizing
fundamental persuasive techniques to help bring awareness and to a moral and financial issue
that is hard to turn away from once a review of the current compelling argument has been made.
After initial marketing materials have been provided, and initial motivation has been established,
the IKP will present local stakeholders with fully formed 501c3 business plan upon request.

Farwell 31
XIII) Capstone Summary
The IKP offers an innovative solution to a complex problem that affects undocumented
dialysis patient clinical health outcomes and weighs down state healthcare spending. The said
problem also contributes to the vast health gap in the United States, and needs to be addressed
through creating programs, such as the IKP. The current detailed capstone and artifact serves as
an initial guide for the first year of program implementation by providing multiple strategies
listed under ERIC model, providing a logic model connecting the solution with the
implementation, provides a description of the implementation procedure as defined through
EPIS, a review of measurements of program target outcomes and processes, an evaluation plan to
ensure program success through year-one and beyond, market analysis, and a timeline for
program rollout as illustrated by the GANTT chart provided. It should be noted that this
implementation plan is preliminary for year one and that we anticipate both outer and inner
barriers (and possibly unforeseen facilitators) that will require ongoing monitoring and
evaluation to allow for program planning and implementation corrections as needed through and
beyond year-one. All successful programs need to account for unforeseen changes to both the
inner and outer contexts in which a program exists, but we are confident that staying true to the
proposed implementation plan and evaluation measures will help ensure that the IKP stays true
to its mission of helping undocumented dialysis patients, help movement toward closing the
health gap in the US, and lower the overall cost of US healthcare.

Farwell 32
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https://www.nytimes.com/2019/02/15/us/politics/national-emergency-trump.html
Traverso, E. (2017). Trump’s Savage Capitalism The Nightmare is Real. World Policy
Journal, 34(1), 13-17.
University of California San Francisco (UCSF)(2013). The Kidney Project. Retrieved February
16, 2019, from https://pharm.ucsf.edu/kidney/need/statistics
Walters, K. L., Spencer, M. S., Smukler, M., Allen, H. L., Andrews, C., Browne, T., & Uehara,
D. (2016). Health equity: Eradicating health inequalities for future
generations. Baltimore, MD: American Academy of Social Work & Social Welfare.
Warren, R., & Kerwin, D. (2017). The 2,000 Mile Wall in Search of a Purpose: Since 2007 Visa
Overstays have Outnumbered Undocumented Border Crossers by a Half Million. Journal
on Migration and Human Security, 5(1), 124-178.
Wilder Research. (August 2009). Program Theory and Logic Models. Retrieved February 25,
2018)
Farwell 40
Zarembo, A., & Gorman, A. (2008, November 9). States find dialysis for illegal immigrants a
costly dilemma. The Seattle Times. Retrieved July 1, 2017, from
http://www.seattletimes.com/nation-world/states-find-dialysis-for-illegal-immigrants-a-
costly-dilemma/

Farwell 41
Addendum 1: InfoGraphic; Immigration & Dialysis Care: Cal vs Texas

Farwell 42
Addendum 2: Year One Residency Canvas (2018)

Farwell 43
Addendum 3: Structured Interviews with Stakeholders
Table 1. Primary Research Interviews
Name Organization Title Expertise/
Reason
Key Takeaways
1 Anonymous Non-profit
Dialysis
Provider
Texas Patient
Service
Coordinator
Insurance
Related
Knowledge
Non-Profit
Perspective
• Provided key data and
information on current
interventions for
insurance issues faced
by undocumented
patients on dialysis in
Texas.
• Spoke about current
Blue Shield Plans,
strengths, and
limitations.
• Spoke about a couple
of successful cases, but
illuminated that
challenge faced by the
large majority of such
patients.
• Provided information
on current solutions,
and real work
experience working
through such issues
with AKF, commercial
health plans, hospital
systems, and outpatient
providers.
• Provided insight into
the sub-culture within
the Texas provider
network
• Provided opinion that a
program such as the
IKP would be
beneficial to patients
and systems.
2 Anonymous

Previous SW
in San
Antonio.
Currently
Social
Services
Texas Social
Work Services
Manager
Knowledge of
Patient Care
(Management) in
Texas
• Provided detailed
information on San
Antonio Tx Acute
Healthcare Hospital
System, as well as
information on
outpatient non-profit
SW manager in Texas.
Farwell 44
Manager San Antonio is where
the program will likely
be first rolled-out.
• Spoke to the regional
needs in Texas, and
spoke to what
opportunities may be
present in different
regions.
• Spoke to the historical
landscape of dialysis
service delivery in
Texas
• Provided additional
information and
perspective on current
insurance plans and
coverage for
undocumented dialysis
patients.
• Spoke to the support
needs of Social
Workers in the region
providing such care
from a more macro
perspective.
• Confirmed that a
program such as the
IKP would be
beneficial in her
opinion, and that said
services are needed
both generally and
specifically for
insurance-related
barriers.
3 Anonymous DaVita
Dialysis
Insurance
Representative
Insurance
Related
Knowledge
For-Profit
Perspective
• All undocumented
patients face some
hardship when on
dialysis, even when in
more sympathetic states
• Undocumented patients
with more financial
resources face
particularly complex
challenges when they
do not qualify for
Medi-Cal
• LDOs provide support,
often even at a financial
Farwell 45
loss.
• Given the LDOs
provide help there are
avenues that the IKP
may benefit such
organizations
• Confirmed from a
personal and
professional opinion
that a non-profit
program, such as the
IKP, that does more
direct work with
patients in the
community would be of
benefit.
4 Anonymous For-Profit
Large Dialysis
Organization
Divisional Lead
Social Worker
Knowledge of
Patient Care
• Emphasized the
importance of
community-based
programs, such as
Catholic Charities for
the undocumented
population.
• Confirmed that the
challenges are complex
for the undocumented
population.
• Illuminated that not all
undocumented
immigrants are the
same and come from
different backgrounds.
• Offered that AZ has
emergency related care
for outpatient services
for this population, but
also indicated that
transplant is not an
option and indicated
that he was unaware of
any program similar to
PRUCOL.
• Help illuminate that
there may be
opportunities for IKP to
start addressing
transplant-related
barriers as well as
outpatient services.
Farwell 46
5 Anonymous Harris County
(Texas)
Hospital
System
Inpatient Social
Worker
Direct
experience with
working with
undocumented
patients on
dialysis in an
acute setting
based in Houston
Texas
• Provided detailed
information on issues
faced by patients in an
acute care setting in
Houston Texas (1.5-
hour
interview)(Previously
Interviewed).
• Spoke to the
pressurized system of
health delivery for
undocumented patients
in Houston.
• Provided insights into
ongoing regional
barriers.
• Provided information
on alternate
considerations and
additional barriers
facing undocumented
dialysis patients.
• Identified areas of
potential reluctance
from hospital
administrators.
• Provided information
on current
interventions, and
strengths and
limitations.
6 Dr. Rajeev
Raghavan,
MD
Baylor
College of
Medicine
- Houston
Texas
Associate
Professor –
Program
Director
Nephrology
Training
Program
Direct
experience as
MD/Researcher
working with
undocumented
patients on
dialysis in an
acute setting.
• Electronic
Communication
ongoing throughout the
DSW program.
• Leading Researcher has
been instrumental in
providing referrals for
further interviews,
guidance, support, and
further insights.

Farwell 47
Addendum 4: Journey Map 1 (Larger Files available upon request)

Addendum 5: IKP Business Plan (Artifact)

Immigrant Kidney Project

501c3 Nonprofit Business Plan

Executive Director:
Ian Farwell, DSW Candidate, LCSW, MSSW, MSG

San Antonio, Texas

Projected Launch Date January 1, 2020

Immigrant Kidney Project

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Non-Disclosure Agreement

The undersigned, hereby agrees that all information contained related to and
regarding the Immigrant Kidney Project (IKP) is private and confidential and will
not be shared or otherwise disseminated to any third or outside party without the
direct agreement or written consent from the Executive Director of the Immigrant
Kidney Project.

The Immigrant Kidney Project leadership team elects to retain on property rights of
information and materials related to the project, and must be returned in full to the
IKP leadership team upon request.

The undersigned individual or organization acknowledges and agrees to the agreed
upon confidentiality agreement, and that the Immigrant Kidney Project may enforce
this agreement in any court of competent jurisdiction.

Date______________________ Signature_________________________________________

Immigrant Kidney Project

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TABLE OF CONTENTS
1.0 Executive Summary................................................................................................... 5
1.1 Introduction...................................................................................................................6
1.2 Problem Identification...................................................................................................6
1.3 Problem Theory.............................................................................................................7
1.4 Target Population...........................................................................................................7
1.5 Proposed Intervention....................................................................................................7
1.6 Intervention Theory.......................................................................................................8

2.0 Organization Description........................................................................................... 9
2.1 Leadership, Administration, & Management................................................................9
2.2 Start-Up Summary.......................................................................................................10
2.3 Location and Facilities.................................................................................................10

3.0 Organizational Services............................................................................................ 11
3.1 Daily Operations and Service Delivery.......................................................................11
3.2 Competitive Comparison.............................................................................................12
3.3 Suppliers......................................................................................................................12
3.4 Leadership Controls.....................................................................................................12
3.5 Administrative Systems...............................................................................................13

4.0 Market Analysis.........................................................................................................14
4.1 Industry Analysis.........................................................................................................14
4.1.1 Market Size...............................................................................................................15
4.1.2 Industry Participants.................................................................................................15
4.1.3 Market Segments......................................................................................................15
4.2 Market Tests.................................................................................................................15
4.3 Market Needs...............................................................................................................16
4.4 Market Trends..............................................................................................................16
4.5 Market Growth.............................................................................................................16
4.5.1 Undocumented Dialysis Patient Service Delivery Market Growth..........................17
4.6 Positioning...................................................................................................................17

5.0 Marketing Strategy and Implementation .............................................................. 18
5.1.1 Strengths...................................................................................................................18
5.1.2 Weaknesses...............................................................................................................18
5.1.3 Opportunities ............................................................................................................19
5.1.4 Threats.......................................................................................................................19
5.1.5 Barrier and Facilitator Analysis – Table 1................................................................20
5.2 Strategy Pyramid..........................................................................................................21
5.3 Unique Selling Proposition and Innovative Value Statement......................................21
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5.4 Competitive Edge.........................................................................................................23
5.5 Marketing Strategy.......................................................................................................23
5.5.1 Pricing Strategy.........................................................................................................24
5.6 Revenue Forecast.........................................................................................................24
5.7 Year One Milestones – Table 2...................................................................................25
6.0 Organizational Structure and Management ..........................................................26
6.1 Star Model – Table 3....................................................................................................26
6.2 Star Model Detail.........................................................................................................26
6.2.1 Strategy.....................................................................................................................27
6.2.2 Structure....................................................................................................................27
6.2.3 Process......................................................................................................................27
6.2.1 Reward......................................................................................................................28
6.2.1 People........................................................................................................................28
6.3 Organizational Chart – Table 4....................................................................................29
6.4 Management Team.......................................................................................................29
6.5 Personnel Plan – Table 5..............................................................................................30

7.0 Financial Plan.............................................................................................................31
7.1 Budget Format and Cycle............................................................................................31
7.2 Revenue Projection......................................................................................................31
7.3 Phases of Intervention..................................................................................................31
7.4 Units of Service............................................................................................................32
7.5 Staffing Plan & Cost....................................................................................................32
7.6 Other Spending Plans & Cost......................................................................................32
7.7 Line Item Budget – Table 6.........................................................................................33
7.8 Revenue vs. Cost Analysis...........................................................................................34
7.9 Financial Tables and Charts.........................................................................................35
7.9.1 Annual Cost of Dialysis Care in Texas 2020 - Table 7............................................35
7.9.2 Revenue Projection 2020 - Table 8...........................................................................36
7.9.3 Revenue Projection 2020 - Table 9...........................................................................37

8.0 Implementation, Monitoring, Data-Driven Decisions, & Sustainment.................38
8.1 Implementation Strategy..............................................................................................38
8.2 Logic Model Description.............................................................................................39
8.2.1 Logic Model – Table 10............................................................................................40
8.3 EPIS Framework..........................................................................................................40
8.3.1 GANTT Chart – Table 11.........................................................................................41
8.4 Measure of Process and Outcome................................................................................42
8.5 Monitoring Plan and Evaluation Procedures...............................................................43

9.0 References...................................................................................................................46

Immigrant Kidney Project

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1.0 Executive Summary

Mission Statement

The Immigrant Kidney Project’s mission is to strive toward empowering
undocumented dialysis patients and families to be able to navigate a complex
insurance and healthcare system in the US through connecting patients with
resources, education, and support.

Value Statement

Every dialysis patient and community member living in the United States, regardless
of their immigration status, is worthy of affordable and more humane outpatient
dialysis treatments.

Initial Year Objectives

v Partner with local hospitals in Texas, and identify at-risk undocumented dialysis
patients in need of innovative and first-of-its-kind IKP services.
v Begin initial outreach to patients and families in need of IKP support and services.
v Ongoing staff education and training to ensure that staff members have the tools they
need to support IKP patients and families.
v Ongoing monitoring and research into program implementation effectiveness and
direct feedback from patient service consumers.
Organization Information & Key Highlights

v Initial funding of $345,000 is expected to yield nearly $10 million yearly to local
hospitals for every 50 patients served, as their “super utilizer” population decreases.
v Initial projections indicate that partnering outpatient dialysis organizations will
increase revenue to just under $4 million dollars for every 50 patients readmitted as
outpatient.
v Research shows that patients have better health outcomes when transitioned from
inpatient care to outpatient dialysis services. Internal research goals anticipate being
able to reflect such patient and family physical and behavioral health/wellbeing
improvements as early as the first year of program implementation.
Growth Highlights

v Year one projections indicate services for 50 patients and their families. Year three
goals include expanding to 150 patients and doubling current clinical staff.
v Year one will target San Antonio Texas, and by year 4/5 all major Texas cities will
be targeted.
(Farwell, 2018)
Immigrant Kidney Project

6
1.1 Introduction

Healthcare faces a pivotal moment in the United States, since the passing of the
Affordable Care Act (ACA). Despite the best efforts of the ACA, to make improvements
to current gaps in healthcare, many healthcare gaps remain (Walters, et al., 2016). The
American Academy of Social Work & Social Welfare has indicated that the current
health gap in the United States is one of the 12 Grand Challenges faced by the field of
Social Work (Walters, et al., 2016). The Academy goes on to describe the current
healthcare gap based on a number of different demographics, such as "race, ethnicity,
gender, age, disability status, geography" and others to name a few. For the purpose of
the current proposal, more close attention will be paid to "geography" and immigration,
and how both affect undocumented patients with kidney failure in the United States.
Specifically, close attention will be paid to how undocumented immigrants are denied
access to more compassionate outpatient dialysis services in Texas, which (second only
to California) has the country's second-largest number of undocumented immigrants, and
other parts of the country (Krogstad, Passel, & Cohn, 2017).
(Farwell, 2017)

1.2 Problem Identification

A number of discriminatory insurance-related barriers are present for undocumented
dialysis patients living with End Stage Renal Disease (ESRD) in the United States, which
has lead to "potentially life-threatening physical" and mental health outcomes for such
patients living in the US in need of maintenance/chronic dialysis (Cervantes, et al.,
2016)(Fernandez & Rodriguez, 2017). More specifically, low-income undocumented
dialysis patients in Texas are often denied access to outpatient dialysis service coverage
under the state's Medicaid program. The issue is complex, but a brief summary should
help to shed light on at least the fundamental challenges faced by undocumented dialysis
patients. Since 1986, Federal Law (EMTALA) mandates that all patients be treated for
emergency conditions, regardless of immigration status or ability to pay for treatment
(Raghaven, 2017). All dialysis patients, regardless of insurance or immigration status,
receive similar care (emergent dialysis) in hospital settings when an acute emergency
arises, which stabilizes the acute medical condition and prevents patients from actively
dying of renal failure (Raghaven, 2017). However, "adequate and cost-effective"
standard practice across the US, following a diagnosis of ESRD in the hospital, is to refer
patients for more compassionate maintenance/chronic dialysis treatment three to four
times per week in an outpatient dialysis setting, yet often barriers present that all but
make access to outpatient dialysis impossible for undocumented patients (Kuruvilla &
Raghaven, 2014)(Grubbs, 2004)(Rodriguez, 2010). The primary mechanism by which
undocumented patients are barred access to outpatient dialysis is related to insurance.
Each state defines what constitutes "emergency" care differently, and thus some states,
like Texas, do not provide outpatient dialysis coverage under Medicaid programs, which
is the "main source of health coverage for non-citizens with serious conditions"
(Rodriguez, 2010). Additionally, undocumented immigrants were largely left out of the
direct benefits of the ACA, insomuch as they were not allowed to purchase commercial
health insurance policies through insurance exchanges established by the ACA
Immigrant Kidney Project

7
(Gusmano, 2012). Moreover, in addition to ethical concerns, outpatient dialysis has been
shown to be "nearly four times" less expensive than hospital-based care in some parts of
the country and there appear to be significant cost-related arguments for allowing
undocumented immigrant access to maintenance dialysis (Raghaven, 2017).

To summarize the issue, research shows that undocumented dialysis patients in many
states face more poor physical and mental health outcomes as a result of discriminatory
state policy interpretations which restrict access to outpatient dialysis care, which is not
only perceived by some experts as medically unethical but also as a draconian set of
policies that cost some states, such as Texas, as much as four times the cost of providing
more compassionate outpatient dialysis care.

1.3 Problem Theory

Of the larger "estimated" "11.1 million undocumented immigrants" in the US, there are
an "estimated 6500 dialysis-dependent undocumented individuals with kidney failure in
the United States" (Fernandez & Rodriguez, 2017)(Raghaven, 2017). Despite a
"dramatic decline in the US undocumented population between 2008 and 2014,"
researchers have argued that "anti-immigrant sentiment has been growing in the U.S."
(Waren & Kerwin, 2017)(Rodriguez, 2010)(Traverso, 2017). It is possible that anti-
immigrant sentiment is one possible reason for the current discriminatory Medicaid
policy interpretations in Texas, which discriminates against undocumented dialysis
patients. Thus, the direct cause appears to be anti-immigrant sentiment, which has lead to
a lack of coverage for compassion outpatient dialysis care coverage in Texas.

1.4 Target Population

The 11.1 million undocumented immigrants in the US are at risk for not have insurance
coverage in the event that they fall ill to ESRD, like the 6,500 undocumented patients
living in the US in need of dialysis or transplant (Fernandez & Rodriguez, 2017).
However, to begin with a more specific target population, San Antonio Texas has been
selected as the initial location, given that Texas has the second largest number (1.6
million estimated as of 2014) of undocumented immigrants (calculated at over 14% of
the countries undocumented immigrants live in Texas)(Kuruvilla & Raghavan, 2014).
Moreover, assuming state distributions of both undocumented immigrants generally and
undocumented immigrants with ESRD are constant and are growing, we estimate that it's
likely that over a thousand undocumented immigrants suffering from ESRD in Texas as
of 2017. California, with the largest number of undocumented immigrants, was not
selected because the state pays for outpatient dialysis services for undocumented patients
under their state Emergency Medi-Cal program.

1.5 Proposed Intervention

Insurance barriers and anti-immigrant xenophobia are two of the primary causes that need
to be addressed in attempting to overcome the issue of discriminatory policy that restricts
undocumented dialysis patients access to outpatient dialysis care. The IKP proposed
Immigrant Kidney Project

8
solution seeks to directly address one of the presenting challenges, which is overcoming
insurance-related barriers for undocumented patients. The Immigrant Kidney Project was
born out of "a novel opportunity to provided scheduled dialysis for (undocumented
ESRD)" which included a process of "(purchasing commercial) insurance off-exchange
(Raghaven, 2017)(Farwell, 2017). The novel solution creatively provides a mechanism
by which undocumented patients are able to first allow their emergency Medicaid
policies to lapse, which then allows them to purchase off-exchange commercial policies.
Off-exchange commercial healthcare policies will pay for outpatient dialysis treatments.
Gaining access to commercial insurance solves the basic issue of access to dialysis
services, but off-exchange commercial policies usually have high premiums that low-
income patients cannot afford. The issue of high premiums is addressed through an
organization called the American Kidney Fund, which helps low-income patients pay all
of their healthcare premiums (American Kidney Fund, 2016). Once patients have an off-
exchange commercial healthcare policy, and premium assistance through AKF, there
appears to be little that can financially stop a patient from gaining access to outpatient
dialysis services.

The IKP is further built from this novel solution and on the understanding that the above-
mentioned solution is complicated, and that the average low-income undocumented
dialysis patient will not be able to navigate such a complex system without professional
support. The IKP will employ Social Workers who partner with local hospitals in
identifying at-risk undocumented dialysis patients and will complete community outreach
to help connect undocumented dialysis patients with outpatient dialysis through the
insurance mechanism described above. Specialized IKP staff will be trained prior to
meeting with undocumented patients and families, and provide insurance education,
education on the benefits of outpatient dialysis services, and guide undocumented
patients on their dialysis-related options. The intervention works for all direct
stakeholders involved, as it helps connect undocumented dialysis patients with more
appropriate outpatient care and better insurance coverage, hospitals will reduce their
share of expensive in-patient dialysis services, and the Large Dialysis Organizations
(LDOs) and other smaller dialysis providers will gain access to a new financially
beneficial patient base with commercial insurance (commercial insurance often has the
highest reimbursement rates).

1.6 Intervention Theory

The Immigrant Kidney Project is novel, innovative, and likely to be a successful
intervention in an area largely untouched. The underlying mechanism for success is in
the benefits to all direct shareholders; dialysis providers, hospitals, and patients.
Insurance companies may be negatively affected, but they appear to be restricted in their
ability to deny coverage to patients based on neither preexisting conditions nor
immigration status (for off-exchange policies) under protection from the ACA.
Interventions that seek to change policy, law, or Medicaid structure will likely face
political headwinds. Therefore, the IKP will provide a maximum benefit, with
minimized resistance, which also circumvents the previous need to change laws
protecting undocumented dialysis patients.
Immigrant Kidney Project

9
2.0 Organization Description

The Immigrant Kidney Project (IKP) has been developed to provide an innovative new
means of subverting harmful social norms affecting undocumented dialysis patients in
many parts of the United States, by increasing equal patient access to care for all while
simultaneously reducing the cost to the state and local hospitals. The Immigrant Kidney
Project will complete its mission by employing a team of highly trained staff to provide
direct services to undocumented patients lacking access to more efficient outpatient
dialysis services, utilizing a research-backed intervention that helps connect
undocumented patients with commercial insurance policies at little to no cost to patients
which should allow patient currently relying upon only Medicaid coverage to
subsequently gain access to more compassionate and better quality outpatient dialysis
services. The Immigrant Kidney Project offers the best hope and innovative solution to
helping the larger effort of improving health outcomes and closing the health gap in the
US for undocumented dialysis patients, while also significantly reducing financial and
other costs to the United States Healthcare system and depressurizing overburden
hospital systems.

Hours of Operation
The IKP will operate during normal business hours
5 days a week with hours as follows:

Monday

9:00 am – 5:00 pm
Tuesday 9:00 am – 5:00 pm
Wednesday 9:00 am – 5:00 pm
Thursday 9:00 am – 5:00 pm
Friday 9:00 am – 5:00 pm

2.1 Leadership, Administration, & Management

The Immigrant Kidney Project will be lead by:
Executive Director Ian Farwell, DSW Candidate, LCSW, MSG

Ian is a Licensed Clinical Social Worker (LCSW) and Gerontologist, and has spent many
years working clinically with undocumented dialysis patients within the non-profit sector.
Ian’s extensive training includes a background in innovation and large systems
management, as he nears the completion of a Doctorate at the University of Southern
California (USC). He also holds two Masters Degrees (Master of Science in Social Work
from Columbia University and a Masters of Science in Gerontology from USC), and also
holds a Bachelor's degree in Psychology from USC. His most recent position was the
Director of Patient Experience at Satellite Healthcare, where he leads the Patient
Experience Program and also provides direct leadership over the Administration
Department of nearly 200 staff servings 8,000 patients living with End Stage Renal
Disease.

Immigrant Kidney Project

10
Under the supervision of the Executive Director, the IKP will recruit and employ an
additional LCSW, Staff Educator, Administrative Leader, and Manager of Volunteers &
Intern Services.

2.2 Start-Up Summary

The projected initial Immigrant Kidney Project annual 2019 start-up budget will be
$345,000 for year one. To meet the revenue goals, a number of revenue sources will
range from hospitals-based funding, large and small dialysis service funding, various
grants, and public donations. The initial budget projections include the cost for office
rent, staff salaries, supplies and equipment, and utilities. As mentioned a mixture of
hospital-based funding, Large Dialysis Organizations (LDO) funding, Small Dialysis
Organization (SDO) funding, grants, and public donations will be used to fund the
program, with the largest emphasis on revenue from hospital-based funding.

At one year, the goal will be to get at least 50 patients connected with Immigrant Kidney
Project support.

2.3 Location and Facilities

The Immigrant Kidney Project Headquarters will be located in central San Antonio
Texas, embedded within a 1,000 square foot office space, providing a professional space
for operations and participant-related meetings with staff. Field staff will also conduct
home and other visits with project participants as an integral part of the project
operational model.

Four states in the United States, Texas, California, Florida, and New York have the
largest number of undocumented immigrants, with Texas being the largest (14.7% of the
undocumented population) state to deny outpatient dialysis Medicaid coverage to
undocumented immigrants (Raghavan, 2018). San Antonio was selected as the nearest
border city facing issues around such challenges. San Antonio has numerous large
hospital systems and offers plentiful opportunity within the IKP's current organizational
and logic model.

Immigrant Kidney Project

11
3.0 Organizational Services

A detailed description of the Immigrant Kidney Project services will be provided which
will include a description of the:

• Daily Operations and Service Delivery
• Competitive Comparison
• Suppliers
• Management Controls
• Administrative Systems
• Future Services

3.1 Daily Operations and Services Delivery

The Immigrant Kidney Project office will operate 5 days per week, and field staff
members will hold meetings with program participants Monday through Friday with
consideration to potentially add Saturday programming in subsequent years depending on
participant population needs. Additional staffing will be recruited in subsequent years
with program growth and expansion.

All field staff will undergo formal and standardized training around key program
interventions and models to ensure the fidelity of change instruments. However, some
clinical liberty will be provided to clinical field staff, and bi-directional learning will be
integral to mission success.

The Executive Director will be responsible to lead the organization toward its mission
of providing services that help close the gap for undocumented dialysis patients in the US
and will have full control of budgetary authority under the guidance of the Board of
Directors. The Executive Director will be responsible for overseeing all day-to-day
operations of the Immigrants Kidney Project, which will include staff recruitment &
retention, financial and program management, ensuring program fidelity, program
growth, outreach with established and future hospital and other professional
organizations, marketing, compliance, and other services.

The Licensed Clinical Social Worker (LCSW) and Staff Educator (SE) will oversee all
clinical aspects of the program reporting directly to the Executive Director. Additionally,
the IKP LCSW and SE will keep staff up-to-date on existing healthcare policy related to
the mission of the organization and will conduct outreach visits to patients coordinating
the connection of undocumented patients with insurance eligibility resources and
subsequent connections with outpatient dialysis units. The LCSW will also provide
supervision to social work interns as needed.

The Board of Directors will be responsible for ensuring the viability of the organization
until the mission has been fulfilled. The board will provide direct guidance and
perspective to the Executive Director and will consist of no less than three members with
diverse backgrounds and expertise.
Immigrant Kidney Project

12
3.2 Competitive Comparison

According to the Center for Disease Control (CDC), over 700,000 patients are being
treated in some capacity in the United States for End-Stage Renal Disease (ESRD)
(Center for Disease Control, 2017). At the intersection of kidney-related care for patients
with ESRD and undocumented immigration, "six states account for 58% of unauthorized
immigrants" with California and Texas holding the largest populations respectively
(Krogstad, Passel, & Cohn, 2017). Despite being the two states with the largest
undocumented population, each state has a different approach to dealing with kidney
disease related care (Fernandez & Rodriguez, 2017). Specifically, California largely
extends outpatient dialysis related care to Medi-Cal (California state Medicaid program)
recipients, whereas Texas largely does not provide such state-sponsored coverage
(Fernandez, 2017). Despite the clinical health outcomes and financial benefits of
providing dialysis related care on an outpatient basis, there has been relatively little to no
significant movement on the issue within states like Texas. The Immigrant Kidney
Project was born out of the research indicating the promising interventions have been
conceptualized but remain without adequate programming ideation or dissemination
(Raghaven, 2017). The Immigrant Kidney Project offers a first-of-its-kind intervention
that is generalizable, scalable, and financially viable. To date, no programs exist in the
current space to provide such programming, and thousands of undocumented patients go
without necessary outpatient maintenance care as a result.

Recent competitive analysis indicates that "the US (dialysis) industry is highly
concentrated: the four (dialysis) companies (DaVita, Dialysis Clinic (DCI), and US Renal
Care, along with Germany-based Fresenius Medical Care...) account for about 85% of
revenue" (Dunn & Bradstreet, 2019). The Immigrant Kidney Project needs only one or
two major partnerships with outpatient providers to ensure scalability, and no such
provider is currently providing same or similar services as the IKP and no such
partnerships exist within the current market.

3.3 Suppliers

Given the service-oriented nature of the Immigrant Kidney Project, few suppliers will be
anticipated. However, suppliers for office supplies and marketing material will be
coordinated between the Executive Director and Administrative Lead.

3.4 Leadership Controls

Leadership control will be spearheaded under the control of the Executive Director, who
will utilize internal research and implementation monitoring to ensure project
effectiveness, integrity, and fidelity. Proper financial accounting will be outsourced to
local accounting agencies, and proper and timely accounting records will be kept and
submitted in accordance with federal and state laws.

Immigrant Kidney Project

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3.5 Administrative Systems

Participant Maintenance System (PMS)
Program Participants will be tracked using Excel spreadsheets, and all updates and logs
will be kept up-to-date by administrative and social work staff. Documentation will be
integrated with research data for program analysis and reporting.

Purchasing / Payables
The IKP Administrative Lead will be responsible for all purchasing and payable accounts
and processing, which will include external vendors and internal reimbursements
processing. The Administrative Lead will carry out such duties under the supervision of
the IKP Executive Director and be verified by the Board of Directors.

Payroll
Payroll management will be lead by the Administrative Lead, and process timecards and
exempt salaries on a semi-monthly structured payroll calendar. Oversight and final
approval will be the responsibility of the Executive Director.

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4.0 Market Analysis

Texas is estimated to provide dialysis related care to over 55,290 patients statewide, with
as many as 6,500 undocumented dialysis patients throughout the US of which an
estimated “30% to 50% of these (undocumented) individuals receive treatment only in
life-threatening situations (emergent dialysis)(Dialysis Patient Citizens, 2019)(Raghavan,
2018). There are a number of Texas-based organizations available to provide education
and insurance-related support, including Texas Renal Coalition, State Health Insurance
Assistance Program, Renal Network #14, and Texas Department of State Health
Services: Kidney Health Program (Dialysis Patient Citizens, 2019). However, these
programs do not offer adequate or equal support to undocumented immigrants. For
example, The Texas Department of State Health Service’s $16.8 million Kidney Health
Care Program is a “non-Medicaid, completely state-funded program for people who have
End Stage Renal Disease... (and) pays for dialysis treatments (for almost 19,000
participants)...” but “(requires that recipients) must be a U.S. citizen” (DPC,
2019)(Health and Human Service 2018). There have been reports that some isolated
Texas counties, such as Bexar County (San Antonio) and Harris County (Houston) have
developed more progressive programs to help limited numbers of undocumented dialysis
patients cover the cost of outpatient dialysis care, but the larger area remains still affected
by a lack of policy or financial resolution (Santiago & Mitre, 2017). In the absence of a
universal and far from comprehensive solutions to the issues facing undocumented
dialysis patients in Texas, programming that can transcend regional differences and
solutions remains necessary.

4.1 Industry Analysis

“The global dialysis services market generates annual revenue of about $86 billion,
according to Fresenius. More than 3 million people worldwide receive dialysis
treatments” (Dunn & Bradstreet, 2019). In the United States, “more than 660,000
Americans are being treated for kidney failure” as of 2016 (National Kidney Foundation,
2016). In Texas alone, there were 50,308 patients on dialysis and a total of 67,435 total
patients living with End Stage renal disease once patients with prior history of transplant
are accounted for (Network 14, 2017). The 50,308 patients on dialysis in Texas are
serviced by 675 dialysis facilities (Network, 2017). More populous states have multiple
Renal Networks, but Texas has only one, which makes the Texas Network the largest
serving 10% of the total national dialysis population (2017).

The Immigrant Kidney Project projects additional revenue of the first 50 patients serviced
by IKP programming to equal nearly $4 million dollars per 50 patients served in year
one, with an upside potential to increase US revenue up to $160 million a year for
dialysis organizations if 2,000 undocumented patients can be successfully rerouted to
more compassionate outpatient dialysis care.

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4.1.1 Market Size

• 3 million dialysis patient Worldwide
• 700,000+ dialysis patients in the United States
• 50,308 dialysis patients in Texas
• At least 6,500 undocumented dialysis patients in the United States
• Estimated around 2,000 undocumented dialysis patients in Texas.

4.1.2 Industry Participants

• DaVita
• Fresenius Medical Services
• US Renal Care
• Dialysis Clinics, Inc.

• San Antonio State Hospital
• Metropolitan Methodist Hospital
• University Hospital
• North Central Baptist Hospital
• Southwest General Hospital
• Methodist Texan Hospital
• Kindred Hospital

4.1.2 Market Segments

Initial Market Segment will be restricted to servicing patients in the San Antonio
Texas healthcare marketplace, who have both been diagnosed with ESRD and have
been unsuccessful at securing outpatient related dialysis care. Future program years,
within 5 years, will be expanded to other cities throughout Texas. Moreover,
subsequent program development will be extended to other states throughout the
United States where similar challenges remain after program year five.

4.2 Market Tests

Preliminary program design modules, community outreach, expert opinion and feedback,
and structured interviews have been conducted to determine program feasibility and
likelihood for success. Interviews included leading expert Dr. Rajeev Raghavan,
anonymous sources from Harris County Hospital System, Divisional Lead Social Worker
from DaVita, anonymous DaVita insurance counselor, Social Services manager for non-
profit dialysis provider in Texas, non-profit dialysis insurance organization counselor for
Texas region, and previous San Antonio Texas based Social Work manager (Farwell,
2018). Leading experts from multiple service delivery points have indicated that the
Immigrant Kidney Projects is necessary, likely to succeed where other programs have
failed, and offers the promise of reshaping an overburdened pressurized system that has
been failing to deliver equitable health outcomes for all participants.
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4.3 Market Needs

Researchers have called for innovative programming that can help close the health gap
experience by undocumented dialysis patients in many parts of the US, due to a lack of
policy resolution (Raghavan, 2012). Additionally, cost containment has become an ever
increasing part of the healthcare services delivery discourse in the United States, as seen
in one of the major goals of the Affordable Care Act is to "support innovative medical
care delivery methods designed to lower the costs of health care generally"
(Healthcare.gov, 2019). The Immigrant Kidney Project aims to address both the calls for
innovative programming and the need for more cost-effective innovation health care
related programming that works toward the larger impact of closing the health gap for
undocumented immigrants.

4.4 Market Trends

1) Affordable Care Act (ACA) 3 Primary Goals: (Healthcare.gov, 2018)
• “Make affordable health insurance available to more people.”
• “Expand the Medicaid program to cover all adults with income below 138% of
the federal poverty level. (Not all states have expanded their Medicaid programs.)
• "Support innovative medical care delivery methods designed to lower costs of
health care generally

2) Some Texas-based counties, such as Harris County and Bexar County have begun
trending toward redirecting county property tax funding and support for undocumented
dialysis patients in need of outpatient care (Santiago & Mitre, 2017).

3) Dialysis organizations have been trending toward a move from In-Center
Hemodialysis to Home-based care that may have implications for future programming
with the Immigrant Kidney Project.

4.5 Market Growth

The incidence of “ESRD is increasing in the United States by 5% per year,” with
“Hispanics (being) 1.5 times more likely to have ESRD” and “African Americans being
3.5 times more likely” (UCSF, 2013).

“The 650,000-plus people who live with ESRD are 1% of the U.S. Medicare population
but account for roughly 7% of the Medicare budget (UCFS, 2013). As the ESRD
population continues to grow, it is likely that the cost of providing dialysis related care
services will also increase.

“The need for donor kidneys in the United States is rising at 8% per year” (UCSF, 2013).
Such trends may also increase the need for space for ongoing and potentially prolong
need for dialysis-related services.

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4.5.1 Undocumented Dialysis Patient Service Delivery Market Growth

In general, immigration-related policy in the United States has reached a pivotal moment
in the US with the election of President Donald Trump and ongoing immigration-related
debate that has included the topic of a border wall, a closer look immigration detention
centers and treatment of detainees, and other immigration-related discussions have
emerged. Recently, President Trump declared a National Emergency on the “border with
Mexico” following a “two-month battle with lawmakers” (The New York Times, 2019).
Stakeholders on either side of the controversy can agree that the issue has become front
and center on a national stage, with may both positive and negative consequences for
undocumented immigrants both living and entering the United States. And, may lead to a
larger population of undocumented immigrants needing access to care depending on
future policy decisions around both health care and immigration. Either way, it is
possible that the number of undocumented patients living in the US may be affected, and
at very least the potential to further marginalize undocumented immigrants in the US is
possible. Additionally, undocumented immigrants who have significant disabilities such
as End Stage Renal Disease seem to be particularly vulnerable to potentially negative
policy changes and developments due to not be able to survive longer than usually a
couple of days without access to some form of dialysis.

4.6 Positioning

As the national discourse on immigration continues and both state and national policy
develop, the Immigrant Kidney Project will remain positioned as the leading advocated
for undocumented dialysis patients and remain committed to closing the health gap
experienced by many undocumented dialysis patients in the United States.

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5.0 Marketing Strategy and Implementation (Barrier and Facilitator Analysis)

The Immigrant Kidney Project is novel, innovative, and likely to be a successful
intervention in an area largely untouched. The underlying mechanism for success is in
the benefit to all direct shareholders; dialysis providers, hospitals, and patients. Insurance
companies may be negatively affected, but they appear to be restricted in their ability to
deny coverage to patients based on neither preexisting conditions nor immigration status
(for off-exchange policies) under protection from the ACA. Interventions that seek to
change policy, law, or Medicaid structure will likely face political headwinds. Thus, the
IKP will provide a maximum benefit, with minimized resistance, which also circumvents
the previous need to change laws protecting undocumented dialysis patients.

5.1.1 Strengths

• Potential for improved health outcomes for undocumented dialysis patients
(Cervantes, et al., 2018).
• Decreases unnecessary costs to local hospital systems providing emergent dialysis
related care only to undocumented immigrants (Raghavan, 2017).
• Depressurized overcrowded hospital emergency rooms.
• Increases revenue for local outpatient dialysis organizations.
• Reduces wasteful tax spending on inefficient hospital-based dialysis related care.
• Provides undocumented dialysis patients with an additional level of support and
advocacy.
• Provides a vehicle to demonstrate the concepts of how outpatient care reduces
cost, which future data can be used within the larger discourse on issues faced by
undocumented immigrants.

5.1.2 Weaknesses

The Immigrant Kidney Project, at least initially, will be a small organization. And,
diversity may be an issue within the program. The Immigrant Kidney Project is an
innovative program that will need to repeatedly innovate as policy and public sentiment
changes over time. Having a diverse staff that understands the needs of the patients, and
is also amenable to change over time, will be an important consideration. Also, being a
small organization may not allow for an array of different staff opinions or staff
backgrounds, until the program can grow during subsequent years. For example, having
only one or two social workers may mean that the program has to rely on translation
services for patients or other means of reaching a more diverse population.

Another important, or even critical, challenge may be funding restrictions as the program
grows. For example, if the Immigrant Kidney Project moves into relationships with
multiple hospitals, some hospitals might place restrictions on the potentially fixed revenue
they provide, and the IKP services for that particular hospital may only be able to be used
for services completed with the affiliated hospital patients or service region. It will be
important to understand how this may affect the organization and service delivery, and
there may need to be separate departments for separate hospitals to ensure that funds are
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only being used as regulated and assigned. Moreover, more affluent hospitals may
provide more funding than community hospitals or clinics, and there may be program
inequality that will need to be addressed internally should such an issue or dynamic arise.
(Farwell, 2018)

5.1.3 Opportunities

• After year one, other locations in Texas remain available for IKP supports.
• After year five, other states within the US remain available for IKP supports.
• After dialysis-related barriers have been largely addressed, issues related to
transplant remain available for additional programming and consideration.
• Additional avenues of advocacy and programming exist for undocumented
immigrants with ESRD, including increased access to training in a preferred
language for monolingual non-English speaking patients, advocacy toward greater
access to home-based modality options, and non-dialysis related health care.

5.1.4 Threats

Insurance providers or affiliated groups or organizations may play a pivotal role as an
external shareholder, and may become a threat depending on how insurance providers
perceive the central intervention provided by the IKP. Although current laws allow for
the purchase of commercial insurance policies (which is the centerpiece of the proposed
IKP intervention), researchers have presented potential examples of ways that
commercial insurance providers may present opposition and advocacy against proposed
interventions (Raghaven, 2017). It remains unclear how policy may be affected or
changed in relation to such efforts from insurance providers, and the Immigrant Kidney
Project may need to be adaptable to such change. (Farwell, 2018).

• Potential policy change that further blocks access to health insurance for
undocumented immigrants
• Potential rejection of intervention strategies by key stakeholders on moral grounds
• Pushback from insurance carriers (although partially insulated by current federal
law)(The United States Department of Health and Human Services, 2017)
• Anti-immigrant protests may become an issue depending on how the program is
perceived in the public eye

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5.1.5 Barrier and Facilitator Analysis

Barriers Facilitators
Exploration
Potential challenges gaining access to
stakeholders that can help determine
program fit may present. Financial
resources during the exploration phase
and prior to implementation may be
scarce.
Sociopolitical momentum around
immigration issues appears present in the
US. Access to large USC database of
research helps facilitate discovery. Many
leading researchers eager to make
progress on the issue helps program gain
traction.
Preparation
Establishing funding may be difficult
before the program has been shown to be
effective. Building a reputation in the
community will take time, and skilled
advocacy will be important in the
preparation phase. The program will be
complex, and skilled programming
leadership will be necessary for program
success.
The IKP generates enormous revenue and
cost savings to local providers and state
health spending, which should serve to
build motivation to support the IKP
efforts. IKP is a non-profit which may
help to build trust d/t the program being
mission, rather than profit, driven.
Implementation
Staff attrition and retraining may present
d/t heavy reliance on internship staff.
The IKP is a new program that will likely
have newness barriers and will need to
adjust to unforeseen changes that have
never been tested in the field.
Being a mission-driven non-profit may
serve to draw dedicated staff that is
willing to find benefit in working with IKP
beyond just financial benefits. Given
immigration issues are center-stage
politically, the IKP may be able to garner
support and well-qualified staff that
support the cause.
Sustainment
Any anti-immigrant policy changes may
affect sustainment. Also, changes in
funding priorities may affect issues
related to IKP success, or overall
shrinking healthcare spending may also
affect programming. Competition from
outside programming may also present if
the IKP proves successful.
Policy changes may become more
immigrant-friendly. Also, funding may
become more available in the future, or
the IKP may be able to secure additional
sources of revenue once the program can
show data in support of program success.

Table 1 (Farwell, 2018)

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5.2 Strategy Pyramid

• Strategy:

Be the leading provider of innovative dialysis-related support to patients
unable to access undocumented dialysis services due to insurance-related
barriers, and subsequently help improve health outcomes for undocumented
dialysis patients and reduce the overall cost to the current healthcare system.

• Tactics:

Conduct community and participant outreach and advocacy, partner with local
hospitals to identify current and at-risk patients without access to adequate
dialysis care, and work alongside outpatient dialysis providers to increase the
number of undocumented patients that gain access to outpatient services.

• Programs:

o Outreach
o Participant Education
o Insurance Counseling
o Psychosocial Support
o Care Coordination
o Participant Follow-up and Monitoring

5.3 Unique Selling Proposition and Innovative Value Statement

Medicaid and Medicare coverage for outpatient dialysis is largely not extended to dialysis
patients in many parts of the United States. As a result of federal policy, requiring
emergency-based care for late-stage kidney disease, emergency room hospitals have
become the only line of care (Raghaven, 2017). A growing body of research remains
relevant and has indicated that "undocumented immigrants with (ESRD) treated with
emergency-only hemodialysis have higher mortality and spend more days in the hospital
than those receiving standard hemodialysis" and that "states and cities should consider
offering standard hemodialysis to undocumented immigrants" (Cervantes, et al., 2018).
However, despite calls from experts to change state and local policy to be more inclusive
of undocumented immigrants on dialysis, laws and policy remain static throughout many
parts of the country making such a near-term reality impossible (Straube, 2009). Until
lasting policy can be reached, non-policy related interventions and programming are
necessary to bridge the gap between policy shortcomings and the needs of our local
communities and patients. It is the aim of the Immigrant Kidney Project to bridge the
gap between program and policy.

Specifically, the initial target of the Immigrant Kidney Project is Texas, because it is the
state that has the largest number of undocumented immigrants (second only to California)
that also does not provide coverage for outpatient dialysis care for undocumented
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22
immigrants under their state Medicaid program (Kuruvilla & Raghaven, 2014). The core
mechanism for the Immigrant Kidney Project was born out of research that presented a
"new opportunity for funding dialysis-dependent undocumented individuals" (Raghaven,
2017). The "opportunity" is that, although the Affordable Care Act (ACA) does not
allow undocumented immigrants to purchase healthcare exchange policies, researchers
have found a loophole that can allow patients to purchase off-exchange policies following
a Qualifying Life Event (QLE), which then is accepted by the outpatient dialysis centers
as an appropriate means of coverage for outpatient treatment (Raghaven, 2017). The IKP
seeks to take this complex "opportunity" and provide highly trained LCSW staff who will
help connect theory to practice by partnering with local hospitals and providing Options
Education and support after discharge. The IKP education and services will include a
connection with commercial off-exchange health insurance policies, American Kidney
Fund (AKF) support, and subsequently result in more adequate outpatient dialysis care
for patients. The program will require minimal staff for maximum effectiveness and has
a dramatic benefit-to-cost ratio. The Immigrant Kidney Project is truly innovative, as it
has never before been attempted in the current or similar format.

Additionally, going beyond the unique program aspects of the Immigrant Kidney Project,
there are also unique financial outcomes created by the Immigrant Kidney Project. First,
it is important to establish that the annual cost of dialysis services in the US is estimated
at $285,000 per patient per year (pppy) of inpatient care, as opposed to only $77,000
pppy (one quarter the cost) when they receive more compassionate outpatient dialysis
care in the community (Fernandez & Rodriguez, 2017; Raghaven, 2017). After doing the
calculations, this means that for every 50 patients that Immigrant Kidney Project serves
there is a potential $14.25 million dollar cost saving per year to local hospitals found in
the reducing of “super utilizers” (ie. undocumented patients requiring ongoing dialysis-
dependent care in an acute setting) and a potential upside to local outpatient dialysis
providers of around $3.85 million dollars per year (Raghaven, 2017). Moreover, the
difference between these two figures indicates a $10.4 million dollar tax savings to the
Texas state Medicaid program. These gains would be sustained year-over-year with little
to no new initial investment for the patients assisted in any given year. Thus, most major
stakeholders (ie. hospitals, dialysis providers, and patients) stand to gain significantly
from the proposed Immigrant Kidney Project. Additionally, since the Immigrant Kidney
Project is modestly seeking to only work with 50 patients in year one, the program is only
tapping at least 5% of the estimated 1,000 to 2,000 undocumented dialysis dependent
immigrants in Texas. If after year one through five the program could be expanded to
closer to 100% of the potential undocumented dialysis patients, and then even further to
other states facing similar issues and barriers, then the financial benefits could potentially
be exponential. A national rollout would be a huge upheaval in the model of care
currently being provided, all while helping close the health gap for undocumented
dialysis patients by improving health outcomes and access.

(Farwell, 2018)

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5.4 Competitive Edge

The Immigrant Kidney Project will have a competitive edge in a number of ways:

• Innovative: The IKP will be first to the space of providing universal programming for
undocumented dialysis patients with ongoing barriers.
• Relevant: The program has been developed with the newest management principals and
understandings.
• Research-Informed: The IKP will be research backed and interventions will be supported
by the research. In other words, the IKP foundational intervention is back on published
research (Raghavan, 2017).
• Research-Monitored: The IKP will continuously monitor and measure current efforts and
utilize and structured and formal implementation plan allowing for adaptability,
scalability, accountability, and fidelity where needed.
• Social Work Model: The IKP program will utilize and capitalize on the strength of the
Social Work model of providing care, support, and education. In other words, there will
be great care and emphasis on providing support and services that are strength-based,
participant-centered, mindful of the need for diversity and inclusion, and sensitive to the
needs of marginalized populations.

5.5 Marketing Strategy

The initial marketing strategy will include leveraging existing relationships and support
for the Immigrant Kidney Project to further develop community partnerships with local
hospitals in San Antonio Texas. The Executive Director, Social Worker, and Board of
Directors will be responsible for initial outreach and ongoing discussion to facility new
organizational partnerships.

Direct referrals from discharge planners from local hospitals will be provided to
undocumented patients with ESRD in local hospitals, and the IKP Social Worker will
follow-up directly in participant’s homes or at the IKP office depending on the preference
of the participants. Additionally, discussion with local dialysis providers will also be a
part of the initial start-up, which will also be accomplished utilizing and leveraging
current relationships with division leads and others in leadership positions. Additionally,
marketing materials can be provided to local hospitals for distribution to patients at the
time of initial referral and conversations. Such marketing materials will include contact
information, program information, and other necessary information. After participants
have begun working with the IKP, ongoing follow-up and care coordination will be
provided to participants. And, it is likely that participant referrals within the local
undocumented community will result following year one and spread through word of
mouth.

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5.5.1 Pricing Strategy

Services provided by the Immigrant Kidney Project will be free to participants and be
fully subsidized by revenue provided by hospital providers, large and small dialysis
organizations, grants, and donations. Additionally, the IKP works to help patients gain
access to commercial insurance policies that they may qualify for and subsequently helps
patients apply for health care premium assistance under the American Kidney Funds
HIPP program. Therefore, participants should be not only able to access services at little
to no cost but also benefit from interventions at little to no cost as well.

5.6 Revenue Forecast

Initial year one roll out includes a plan to include 50 participant referrals from local
hospital partnerships in San Antonio Texas. Year two plans include a move to 100
patients, followed by access to all in-need participants in San Antonio year three. Year
four will include opening projects through Texas and other major cities. Year five will
include plans to venture beyond Texas to other states facing similar challenges
throughout the United States.

Initial estimates (see the financial plan in section 7.0) indicate that $345,000 in revenue
will be needed to support every 50 patients for their first year in the program.
Participants that successfully move through the IKP program in 12 months or less will
likely not require additional funding but continues to provide financial benefit to both
hospitals and outpatient dialysis provider systems as long as they remain on their
commercial health plans and continue to receive primarily outpatient dialysis services no
longer requiring ongoing emergency dialysis in the hospital setting. Revenue estimates
may need to be slightly increased for any patients that are unable to gain access to
commercial insurance (ie. lack of participant timely follow-up, deportation, etc.), and
revenue estimate will be re-evaluated continuously at year end, year over year.

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5.7 Year One Milestones (with GANNT Chart)

Milestone Completion Date
Initial Partnership Discussion 1/31/2020
Rental Office Established 1/31/2020
Staff Training Completed 2/1/2020
Initial Participant Outreach (Start) 4/1/2020
Program Data Collection 4/2020 - 12/2020
Program Data Evaluation 10/31/2020
Data Reporting 11/31/2020
Program Adjustment / Planning Yr2 12/31/2020

Table 2

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6.0 Organizational Structure and Management

The structure of the Immigrant Kidney Project will be that of a 501c3 non-profit
organization and will be lead by an experienced Executive Director. There will a diverse
Board of Directors (BOD) that will help guide the organization year over year, and
provide a diverse range of perspectives and wisdom on a range of expertise, such as law,
policy, leadership, etc. And, an organizational chart (see Table 4; Section 6.3) has been
developed to illustrate not only the IKP staff positions but also the flow of accountability.

6.1 Star Model

In designing the Immigrant Kidney Project, a “strategic organizational design” known as
the “Star Model” was used to conceptualize the program from a “holistic way of thinking
about (the) organization” (Galbraith, 2014). The Star Model includes 5 areas of
organization structure that need to be developed, which include “strategy,” “structure,”
“processes,” “people,” and “rewards” (See Table 3; Section 6.1)(Galbraith, 2014).

Table 3 (Farwell, 2018)

6.2 Star Model Detail

Greater detail will be provided for each of the five pillars of the Star Model will be
reviewed in great detail:

• Strategy
• Structure
• Processes
• Rewards
• People
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6.2.1 Strategy

There will be three aspects to the Immigrant Kidney Project organizational strategy, as
advised by the Star Model, which will include “growth,” region, and quality (Galbraith,
2014). First, IKP will have the goal of growing beyond the initial 50 patients, until all of
the thousands of undocumented dialysis patients in the US have access to outpatient
dialysis services. Second, our year one strategy will be to focus on undocumented
dialysis patients in Texas but may be expanded in subsequent years to the greater US.
Lastly, in order to stay relevant and provide the overall best quality of service to patients
and families, our staff will strategically focus on staying up-to-date on the most current
laws and policies affecting our patient population and therefore advise patients on the
best options for gaining access to outpatient dialysis services.

6.2.2 Structure

The structure of the IKP will be that of a 501c3 non-profit organization and will
be lead by an experienced Executive Director. There will a diverse Board of Directors
(BOD) that will help guide the organization year over year, and provide a diverse range
of perspectives and wisdom on a range of expertise, such as law, policy, leadership, etc.
And, an organizational chart has been developed and provided below to illustrate not only
the IKP staff positions but also the flow of accountability (See Table 4; Section 6.3).

6.2.3 Process

There are a number of different organizational processes that need to be
considered before rolling out the IKP. First, information flow will be non-linear at first,
given the small number of staff members. In other words, all members of the
organization will transcend lines of accountability when it comes to information flow,
and the organization will encourage and promote discussion across formal accountability
boundaries. The Executive Director will reach out to all levels of the organization
frequently to gain feedback on organizational health and system updates. Moreover, staff
will engage in a multidirectional communication line between LCSW, admin staff,
volunteer, and intern services. The flow of information may become more formalized as
the IKP grows, especially if the programs expand into other states, but initially a strategic
pilot of decentralized power will be explored and tested. Second, the business process
will include the use of the LCSW, interns, and volunteers to conduct community outreach
to patients and families to ensure that they are connected with services; while the
Executive Director and Board of Directors look to grow the organization beyond the
initial local region. Lastly, the management team and leadership conduct its management
process by taking a stance of bottom-up processing and spend significant time listening
and learning from staff that are in the field day-to-day. The Board of Directors and
Executive Director will be responsible for setting yearly budgets and working with staff
to ensure program sustainability and effectiveness at achieving the mission and ensuring
that the strategy of promoting organizational values occurs in the community.

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6.2.4 Reward

A system of providing work incentives and rewards is critical in organizational
development. The goal of IKP will be to provide a competitive compensation package
for staff that will include a full benefits package. The underlying rewards philosophy
will be that a happy, healthy, and balanced workforce will be more successful, efficient,
and productive. After the first year of success, and significant return on investment for
local hospitals and LDOs, staff salaries should be able to rise significantly and benefit
programs expanded to meet the needs of staff and cost of living. In addition to
competitive salaries, benefits packages will include medical, dental, vision, 403b
matching, an employee assistance program, paid time off, holiday pay, disability
insurance, and other supports. As the program grows, a bonus structure may also be
considered to incentives and maximize the number of patients that gain access to
outpatient dialysis services.

6.2.5 People

The most important part of IKP will be the people that help improve the quality of
life for the undocumented dialysis patients that we serve. It will be important to
incorporate a diverse group of the most talented and driven staff. Toward such an end,
the Bridge Builder Program will partner with the best local schools to utilize the best
interns and volunteers from the community. A complex interview and hiring process will
also be utilized for paid staff, in order to find individuals with the right "mindset,"
professional experience, and skill to be successful at helping connect patients to
outpatient services (Galbraith, 2014). (Farwell, 2018)

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6.3 Organizational Structure Chart

Initial staffing plans will include an Executive Director, LCSW & Staff Educator,
Administration Staff, and Manager of Volunteer & Intern Services. Early on in the
program development and implementation, all staff will be critical to the success of the
organization. Guidance and leadership will be pivotal because the Immigrant Kidney
Project will be innovative and one-of-a-kind, and therefore unforeseen hurdles may
present that needs leadership. Additionally, and dedicated and passionate Social Work
staff will need to not only be trained initially but remain passionate about learning about
the system as it changes in response to the IKP intervention. And lastly, administrative
and volunteer staff will be the central staff component that makes day-to-day operations
flow and function seamlessly. Without any one group within the team, the program
would struggle in its infancy. (Farwell, 2018)

Board of Directors

ê

ê

Executive Director

í ç ç ê è è è è î

ê

ê

ê

LCSW/Staff
Educator

Administrative
Coordinator

Manager of Volunteer & Intern
Services

ê

ê

Interns

Volunteers

Table 4 (Farwell, 2017)

6.4 Management Team

First-year leadership will be spearheaded by the Executive Director (ED), LCSW and
staff Educator, and Manager of Volunteer & Intern Services. The ED will largely help
close gaps and personnel shortages during the earlier period of program implementation,
but as the program expands in subsequent years then other staff will be added to help
support the role of the ED and other leadership positions.

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6.5 Personnel Plan

Personnel FTE Salary
Executive Director 1 $65,000
LCSW & Staff Educator 1 $55,000
Administrative Lead 1 $35,000
Manager of Volunteer & Intern Services 1 $45,000
Total Benefits (17% of Salary) $40,000
Total Year One Labor Cost $240,000
Table 5

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7.0 Financial Plan

The following sections provide an overview of the IKP financial plan:

• Budget Format and Cycle
• Revenue Projection
• Phases of Intervention
• Units of Service
• Staffing Plan & Costs
• Other Spending Plans & Costs
• Line Item Budget
• Revenue vs. Cost Analysis

7.1 Budget Format and Cycle

The format of the current budget allocation will be in the form of a Line Item Budget,
showing expected revenue and anticipated expenses that the IKP will incur during the
upcoming Calendar Year January 2020 through December 2020.

7.2 Revenue Projection

The projected initial annual 2020 start-up budget for the IKP will be $345,000. To meet
the revenue goals, a number of revenue sources ranging from hospitals-based funding,
large and small dialysis service funding, various grants, and potentially public donations
will be necessary.

7.3 Phases of Intervention

There are a number of phases that an IKP participant will need to go through in order to
benefits from the program. First, patients would need to speak with local IKP outreach
workers in the participating hospitals in the language of choice. Second, follow-up visits
with patients and family will need to be conducted outside the hospital following
discharge. A trained Masters-Level Renal Social Worker will need to meet with patient
and family during these visit to discuss benefits of outpatient care, benefits of full-scope
commercial insurance coverage, risks and rights of the patient, limitations of IKP,
additional supporting applications for insurance exchanges and American Kidney Fund
HIPP program support, and availability of additional long-term support should patients
lose their insurance coverage at future date. Once a patient undergoes a qualifying life
event (QLE) and can enroll in a commercial insurance policy, the participant may also
need further peripheral support as they potentially transition back through hospital setting
and into an accepting outpatient dialysis unit, which the IKP Social Worker will be
available to assist through the process to ensure that interventions have been successful.
Once the participant has been successfully established with a local outpatient dialysis unit
for 90days (the period where dialysis patients are most vulnerable), the Social Worker
can then move to discontinue services. The IKP Participants will have the ability to
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contact the IKP support in the future, should they lose insurance coverage or experience
other barriers to long-term outpatient dialysis care.

7.4 Units of Service

The number of ESRD patients that move from inpatient hospital-based care, through the
Immigrant Kidney Project, and into outpatient dialysis care for a period of 90 continuous
days within one calendar year January 1, 2020 to December 31, 2020 will be the primary
unit of service. Subsequent units of service may also include a more macro perspective
in the number of hospital-based partners that can be recruited to provide patient referrals,
but initial start-up requirements will be likely be based on one or two hospital systems
and dialysis partners.

7.5 Staffing Plan & Costs

• Executive Director FTE = 1 _ Salary = $65,000
• LCSW & Staff Educator FTE = 1 _ Salary = $55,000
• Administrative Staff FTE = 1 _ Salary = $35,000
• Manager of Volunteer & Intern Services FTE = 1 _ Salary = $45,000
• Benefits = $40,000 (17% of Salary)

Total Year 1 Labor Cost = $240,000

7.6 Other Spending Plans & Costs

Office rent, office supplies, office equipment, utilities, and other services will be
necessary as follows. It will be important the first office be local to funding hospitals, as
they will simultaneously be the primary funder and referral source for the first 50
patients.

• Rent $1500 per month / $18,000 annually
• Office Supplies $10,000 annually
• Office Equipment $15,000 annually
• Utilities $5000 annually
• Misc Operation Cost = $12,000 annually

Total Year 1 Non-Labor Operating Cost = $60,000

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7.7 Line Item Budget

Immigrant Kidney Project 2020 Budget Projection
Bridge Builder Budget: Calendar Year 2020
Revenue Annual
Hospital-Based Funding $270,000
Large Dialysis Funding $50,000
Small Dialysis Funding $10,000
Grants $10,000
Donations $5,000
Total Revenue $345,000

Expenses

Personnel Expenses

Executive Director $65,000
Clinicians LCSW $55,000
Volunteer & Intern Manager $45,000
Admin Staff $35,000
Benefits $40,000
Total Personnel $240,000

Operating Expense

Rent $18,000 ($1,500 Monthly)
Office Supplies $10,000
Office Equipment $15,000
Utilities $5,000
Misc. Operation Expense $57,000
Total Operations $105,000

Total Expense $345,000

Surplus/Deficit $0

Table 6 (Adapted from Farwell, 2017)

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7.8 Revenue vs. Cost Analysis

Original revenue estimates appear accurate and on target when considering necessary
program expenses. Additionally, given the potential $10.4 million dollar savings to local
hospitals & government insurance providers, and the potential increase in revenue of up
to $3.85 million dollars for local dialysis organizations, resulting from IKP interventions,
there will also likely be room to discuss growth opportunities and expansion after year
one. Additionally, the initial $345,000 revenue could be easily expanded given the
current organization structure and financial model. Specifically, IKP has an
organizational structure that proportionally becomes more valuable as volume increases.
For example, if a 50-patient census yields a potential $10.4 million dollar savings to local
hospitals, then a 100-patient census yields $20.8 million dollar savings in theory.
Moreover, it will likely not be necessary to carry participants over from year to year to
obtain the same results. For instance, a second year of 50 new participants will yield an
additional $10.4 million dollars or more in potential savings. Thus, organizational cost
would not need to increase year-over-year, yet still allow for cumulative cost savings to
local hospitals to double annually without increasing base program expenditures (annual
inflation and cost of living adjustments would need to rise, but the rise would likely
marginally near $50,000 per operation year and relative across the industry).

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7.9 Financial Tables and Charts

The following charts will help illustrate the projected IKP financial plan and helps to
provide a detailed illustration of the proposed program financial data.

7.9.1 Annual Cost of Dialysis Care in Texas - Table 8

Table 7 (Farwell, 2018)

$0
$50,000
$100,000
$150,000
$200,000
$250,000
$300,000
Annual Cost of Dialysis Care Texas
Annual Cost of
Dialysis Care
Texas
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7.9.2 Revenue Projection 2020 - Table 9

Table 8 (Farwell, 2018)

Hospital
LDO
SDO
Grants &
Donations
2020 IKP Revenue Projection
$270,000
$50,000
$25,000
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7.9.3 Expense Projection 2020 - Table 10

Table 9 (Farwell, 2018)

Labor Cost
Operating Cost
2020 IKP Expense Projection
$240,000
$105,000
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8.0 Implementation, Monitoring, Data-Driven Decisions, & Sustainment

A key strength of the Immigrant Kidney Project is the program has been designed using
structured planning tools and incorporates a tested framework to ensure program success
and the ability to communicate with major stakeholders. To provide great understanding
and detail, and implementation and monitoring highlights will be presented as follows:

• Implementation Strategy
• Logic Model Detail
• EPIS Framework
• Measure of Process and Outcome
• Monitoring Plan and Evaluation Procedures

8.1 Implementation Strategy

In order to ensure successful implementation, it is imperative that the IKP select and
follow an implementation strategy. The IKP has selected a number of relevant strategies
with the assistance of the Expert Recommendations for Implementing Change (ERIC)
table (Brownson, Colditz, & Proctor, 2017). There were a total of five strategies across a
total of three strategy categories. The three categories include the “use of evaluative and
iterative strategies,” “develop stakeholder interrelationships,” and “utilize financial
strategies” (Brownson, Colditz, & Proctor, 2017). Within said categories, the five
selected strategies include, “Audit and provide feedback,” “Develop a formal
implementation blueprint,” “Obtain and use patient/consumer and family feedback,”
“develop academic partnerships,” and “access new funding” (Brownson, Colditz, &
Proctor, 2017). Each one of the strategies has been selected carefully to target areas of
program implementation that are critical for program success.

First, the audit and feedback strategy will allow the IKP to “summarize clinical
performance data over time...” “and provide it to clinicians and administrators to monitor,
evaluate, and modify” IKP behavior (see subsequent Measurement section for greater
detail)(Brownson, Colditz, & Proctor, 2017). Monitoring clinical performance pre/post
intervention will allow for changes in programming to meet the needs of patients and
families, which leads to the second strategy of obtaining patient and family feedback. In
addition to objective clinical measures, qualitative feedback will be requested from
patients and families being served to measure subjective levels of success as measured by
the patients/families the IKP serves. Additionally, another strategy will be to develop
academic partnerships, which has already begun with the connection of Dr. Raghavan
who is a leading researcher on the issue and at the forefront of research on the issue
(Raghavan, 2017). Beyond the clinical elements of the program, administration and
funding are going to be mission-critical, and the financial strategy of accessing new
funding will be a major part of the implementation strategy.

So far, a funding strategy, a patient-centered monitoring strategy, a clinical performance
monitoring strategy, and an academic partnership collaboration strategy have been
selected and discussed, but all of these smaller strategies will be worked into a larger
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strategy of developing an overarching “formal implementation blueprint” (Brownson,
Colditz, & Proctor, 2017). The larger blueprint will serve as a detailed map of how the
overall implementation strategy will be conducted and will be frequently revisited on a
monthly basis by program leadership to allow for implementation plan changes as
needed. The reason for the larger implementation plan is a result of the fact that the IKP
is a dynamic program, with many moving parts and a number of significant stakeholders,
which include patients, families, large and small hospital systems, large and small
dialysis organizations, researchers, nephrologists, insurance providers, potentially
politicians, and other stakeholders. In other words, multiple implementation strategies
within a larger overarching strategy were selected as a strategies-within-a-strategy
model, which was an attempt to monitor varying aspects or parts of the organization and
account for the great program complexity that is anticipated. For example, it will be
important to not only monitor patient outcomes, but also funder relationships, new or
updated academic evidence-based practices or research, and other areas that seemingly
have little to do with each other directly yet coalesce into critical aspects or segments of
the IKP programming and design.
(Farwell, 2018)

8.2 Logic Model Description

A logic model has been provided that highlights key steps inherent within the IKP
intervention (see Table 10)(Wilder, 2008). The IKP logic model provides a workflow,
starting with inputs followed by activities, outputs, outcomes, and overall impacts of the
IKP. First, trained Master-Level Medical Social Work (MSW) staff will be trained and
start to work with patients around a novel researched-back intervention detailed in
"activities." Specifically, MSW staff will engage in activities such as providing support
to, assistance, and education around complex insurance loopholes that can directly
benefit undocumented dialysis patients in states like Texas. The output goal is expected
to see a significant number (>95%) of undocumented IKP patients gain more adequate
insurance coverage and access to outpatient dialysis care. Subsequently, such outcomes
should lead to better health outcomes and overall improved patient wellbeing. The larger
impact of such IKP and patient outcomes is an overall reduction in health inequality in
the United States and a move toward the closing of the Health Gap previous cited by the
AASWSW. There are clearly other interventions that could correct the issues facing
undocumented dialysis patients, like changing current laws to allow outpatient dialysis
coverage for undocumented patients in Texas. However, as the research has shown, such
interventions have been resistant to implementation (Rodriguez, 2010). Thus, as
researchers have noted, the intervention inherent within the above logic model appears to
be the most promising intervention given the current environment (Raghavan, 2017).

(Farwell, 2018)

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8.2.1 Logic Model

Table 10 (Farwell, 2018; Wilder, 2008)

8.3 EPIS Framework

The EPIS framework has been chosen as the implementation framework selected to help
guide the IKP development process, which goes through the four stages of Exploration,
Preparation, Implementation, and Sustainment (SAMHSA, 2018)(See Table 11).
Additionally, a GANTT chart has been provided to help set the timeline for rolling out
the EPIS framework as applied to the IKP.

During the exploration phase, it is important to consider whether such an intervention
should be adopted and consider if such an intervention will be successful at addressing
the intended target goal. There appears to be research that suggests that the program core
intervention can and will work and therefore should be adopted (Grupta & Fenvez,
2017)(Raghavan, 2017)(Sheikh-Hamad, et al., 2007). Ideally, this continued exploration
phase would take place during the first three months (January through March) of the
programs official start date. The exploration phase will consist of exploring many
clinical factors, identifying potential funders, developing a communications plan,
exploring the best organizational structure in each market, conducting market analysis,
and more generally exploring the city and state landscape with regard to barriers and
facilitators.

The preparation phase will begin near the end of the exploration phase, between March
and April of the implementation year. The preparation stage will include both external
and internal aspects, and such considerations will include initial projections for
budgeting, staffing, funder and stakeholder relationship development, interagency
partnerships, fundraising plans, tax/licensing and IRS non-profit filing plans, permitting
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plans, and overall detailed project plan. A well-prepared program will be critical in the
successful implementation to follow.

Following the preparation phase, the IKP will move to implementation. Initial
implementation will begin in San Antonio Texas, and then subsequently move through
the US to other parts of the country with similar challenges. Successful implementation
will be contingent upon making sure program administrators adhere to the initial
preparation plan while also being flexible to change as needed in the early phases of the
program. There are a number of key implementation goals that present during
implementation, which include but not limited to making sure staff is trained to clearly
understand the key IKP intervention, develop an effective strategy for helping connect
patients and families with said interventions, retraining volunteer and internship staff
through anticipated yearly attrition, monitoring said adherence and fidelity to key
interventions while also allowing for staff to adapt interventions as needed, conduct
research ongoing to ensure that the program is both relevant and effective over time, and
working toward program growth and expansion.

The final stage of the implementation framework selected will be sustainment. The
sustainment phase will begin officially during the last quarter of year one (October) and
carry through year-end (December). Sustainment will be a critical phase in which
program effectiveness will be measured, and include project performance measures, cost
tracking, monitoring of adherence to project objectives, and potential forecasting leading
into a return to the exploration phase for program year-two. Such evidence will help
determine program success, and help inform of how to move forward into year-two and
beyond. For example, findings from the sustainment phase may determine if the program
is ready to be expanded to other Texas cities or other states that face similar challenges,
or if changes need to be made to address funder or other stakeholder concerns or issues.
More detail on measures and monitoring plan will be provided in subsequent sections,
and a detailed table of the barriers and facilitators at each of the EPIS stages has been
provided (see Table 1). (Farwell, 2018)

8.3.1 GANNT Chart

GANNT (General EPIC Overview)
Task
Q1
2020
Q2
2020
Q3
2020
Q4
2020
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Exploration

& Research

Preparation

Implement

Sustainment
Table 11 (Adapted from Farwell, 2017)

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8.4 Measure of Process and Outcome

To ensure that the IKP is actively working toward its mission, it will remain important
that that process and outcome measurements be gathered, evaluated, and monitoring
ongoing as part of the sustainment phase of EPIS previously identified as the leading
program framework to be adopted.

First, the outcome measures will be measured along a number of different dependent
variables during the sustainment and program evaluation phase of implementation. The
goal of the program is to improve patient mortality and morbidity rates, while also
increasing patient overall wellbeing by connecting patients with outpatient dialysis
services. Thus, the first goal will be to help patients gain access to outpatient dialysis.
Therefore, frequency counts will be conducted allowing for data that illustrates how
many patients are able to assess adequate insurance coverage, subsequently access
outpatient care, and sustain access to outpatient care beyond year-one. Once patients
have gained access to outpatient care, pre/post-test mortality rates will be gathered
annually for all program participants, along with other dialysis-related clinic lab data (ie.,
Kt/V, K, Creatinine, & GFR). Patient overall subjective well-being will be measured
using industry standard tool The Kidney Disease Quality of Life (KDQOL) survey,
which is consistent with what outpatient dialysis patients are provided nationally, and
also the use of the Patient Health Questionaire-9 to assess for the presence of mood-
related challenges pre/post-IKP administration. Moreover, in addition to the quantitative
data just mentioned, Social Work interns who can gather program feedback from patients
and families will conduct open-ended qualitative measurements and surveys. Common
themes or innovative program ideas will be generated from this information to inform
future program strategy and programming. Additionally, it will be necessary to monitor
financial data, which will include the amount of money the IKP saves taxpayers through
innovative programming that shifts cost as a result of moving patients from inpatient to
outpatient care, which is projected at nearly "$10 million yearly (savings) to local
hospitals (and taxpayers) for every 50 patients served" by the IKP and nearly $4 million
in outpatient dialysis center new revenue generation (Farwell, 2018)(Raghavan, 2017).
Such data will likely be valuable in illustrating financial outcomes and the benefits of
IKP interventions, and will likely allow for continued funding support from current
financiers and also possibly draw new sources of funding as program success can be
shown with such measures.

In addition to the outcome measures mentioned, measurements of process will be
necessary to ensure that program Social Worker staff members are adhering to the
intervention cited in the literature, to ensure program intervention fidelity. Monthly
qualitative debriefs will be conducted between the IKP Executive Director (ED) and
Licensed Clinical Social Work (LCSW) staff to review self-reports of interactions with
patients where barriers to intervention effectiveness persist longer than six months. In
other words, when patients either do not gain adequate insurance coverage to cover
outpatient dialysis services, or fail to gain access to outpatient services once insurance
has been secured, the ED and LCSW will review such challenging cases to determine if
process corrections can be made or if intervention adaptations are necessary at the micro
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level. Subsequently, at year-end, the ED will review all cases that trigger for inefficient
intervention outcomes (patients without insurance or outpatient care within six months of
program entrance), and review data with program leadership and LCSW to determine if
global themes emerge and if intervention changes are necessary on a macro level.

8.5 Monitoring Plan and Evaluation

The framework for measuring IKP effectiveness will be along four main lines, each over
time intervals of 12-month ongoing. The four main domains that program effectiveness
and accountability will be measured include patient health outcomes (both subjective and
objective measures), program cost/value to external stakeholders, scalability, and
comparative market analysis. Each domain will be measured differently and needs to be
further expanded upon in detail. Before getting to a more detailed description of each
domain, it should also be noted that IKP program success will be contingent upon
becoming effective in all of the four domains. In other words, in order to be deemed
effective by our internal standards the program must be shown empirically to 1) improve
patient clinical health outcomes on a 2) large scale with a program that is 3) financially
viable and provides such a service that is 4) of equal or greater effectiveness than other
any similar programs (should such programs emerge).

An important first step would be to establish that the work of the IKP is helping patients
from both an objective and a subjective standpoint. Even though previous research has
shown that the IKP intervention (which helps connect patients with commercial insurance
and outpatient dialysis services) improves health outcomes for undocumented patients, it
is important to make sure the same IKP interventions are also producing the same or
similar results as previously found. Therefore, an important first step is to replicate
previous findings from research in the field. Specifically, a randomized experimental
design will be used to measure pre-admission and post-admission "patient utilization of
hospital service" rates (number of hospital admissions and length of stay in a given
period) and patient "self-perceived satisfaction" as measured by validated measurement
tools such as previously-mentioned The Kidney Disease Quality of Life Measure
(KDQOL) and mood-related nine-question Patient Health Questionnaire (PHQ-
9)(Sheikh-Hamad, 2007)(Kroenke & Spitzer, 2002)(Hays, et al., 1994). Additionally, as
mentioned previously, patient clinical lab values will be reviewed with a patient release,
and patient clinical indicators can be monitored for improvements after starting with the
IKP and gaining access to outpatient services to provide for objective measures of health.
IKP patients will be measured in an experimental waitlist design against a control group
of non-IKP patients that have been diagnosed with ESRD, but will receive no treatment
change (or no referral for IKP services remaining with hospital-based care)(Control
group patients may be referred at a later date after monitoring has concluded)(groups will
be randomized and monitored to account for race, socioeconomic status, age, gender,
dialysis outpatient treatment modality, history of transplant, length of time on dialysis,
and, geographical location, and cause of renal failure to reduce the potential effects of
extraneous variable). The above-mentioned experimental design will be conducted by a
third party subcontracted research agency, and services have been carved out of the initial
IKP program budget. The initial 50 patients to enter the program during year-one will be
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the first group of patients to be monitored against a set of 50 patients that have been
waitlisted for IKP services, which are anticipated to enter the IKP program during year-
two. Statistical analysis will be conducted across the two groups, which will include Chi-
Squared tests to determine statistical significance for the IKP Intervention with regard to
overall mortality rates at 1 year. A theoretical example analysis has been provided as
follows (see Table 12).

Table 12: (Theoretical example)

In addition to patient health outcomes, it is important for program stability and long-term
viability to be able to show that the IKP helps reduce the cost to hospitals and also
generates revenue for local dialysis providers. A simple pre-test/post-test of money spent
on IKP patients versus non-IKP patients will be identified during the previously-
mentioned experimental design. The facts and figures will allow IKP leadership to
showcase the inherent economic and financial value of the IKP to shareholders, such as
local hospitals, policymakers, insurance providers, dialysis providers, and miscellaneous
other potential funders.

Hospital systems through the country exist within local and political contexts with a high
amount of variability. In other words, every hospital system servicing undocumented
patients on dialysis exists within highly idiosyncratic and variable legal, political, and
financial subsystems. However, we theorize that the IKP is capable of transcending such
subsystems given the current protections under federal policy. The real innovation of the
IKP is that it should be scalable to all parts of the US, given current legislation.
Therefore, to show the true innovation of the IKP, it would important to show evidence
that the program can expand rapidly (within 5 years) through the US. To measure
scalability, frequency counts of multiple measures will be calculated to show growth.
Such frequency-count measures will include the total number of patients served by the
IKP, the number of hospitals served by the IKP, and the number of cities and states that
the IKP operates within. Later, to show scalability relative to the larger issue of closing
the health gap for undocumented patients on dialysis, the previous frequency counts can
be shown as a percentage of the estimated "6500" undocumented dialysis patient on
dialysis in the US (Raghavan, 2017). All the above measures will be calculated at 12-
months intervals, which then can also show program growth rates over time, and provide
for future projections allowing for program changes and new directions as needed
(Raghaven, 2017). In addition to measuring scalability, it will be important to also
conduct market analysis research to compare the IKP to other programs in the future,
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should such programs come to exist. Said annual market analysis would be beneficial to
maintain the most up-to-date programming, and ensure that IKP is using the most
effective and evidence-based solutions for patients in any given market.

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Baylis, J., Owens, P., & Smith, S. (Eds.). (2017). The globalization of world politics: An
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Blagg, C. R. (2007). The early history of dialysis for chronic renal failure in the United
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Brownson, R. C., Colditz, G. A., & Proctor, E. K. (2017). Dissemination and
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Cervantes, L., Fischer, S., Berlinger, N., Zabalaga, M., Camacho, C., Linas, S., & Ortega,
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Ewing, W. A. (2012). Opportunity and exclusion: A brief history of US immigration
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Asset Metadata

Creator Farwell, Ian Michael James (author)

Core Title Immigrant Kidney Project: connecting undocumented dialysis patients with more compassionate and cost-effective quality outpatient care

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Publication Date 05/13/2019

Defense Date 04/11/2019

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag dialysis,immigration,OAI-PMH Harvest

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Southard, Marvin James (committee chair), Celis, Olivia (committee member), Enrile, Annalisa V. (committee member)

Creator Email ianfarwellmsg@gmail.com,ifarwell@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-169385

Unique identifier UC11660616

Identifier etd-FarwellIan-7446.pdf (filename),usctheses-c89-169385 (legacy record id)

Legacy Identifier etd-FarwellIan-7446.pdf

Dmrecord 169385

Document Type Capstone project

Format application/pdf (imt)

Rights Farwell, Ian Michael James

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA