Partner Clinic Application

This Partner Clinic Application is intended for institutions providing adult PKD care and that would like to be designated as a Partner Clinic within the PKD Foundation Centers of Excellence Program.

Application Instructions

• Complete the entire application using this form.
• You may save your progress and return later by selecting “Save” at the bottom of each page.
• A direct link to resume your application will be sent to your email the first time you click “Save.” Please note that additional “Save” clicks will not generate a new email. To return to your application, you will need to use the link provided in the original “Save and Return” email.
• All applications are due by Friday, August 28 at 5:00 PM CT.
• The form will close at that time; late submissions will not be accepted.
• Questions? Contact carecenters@pkdcure.org.

Please note: This year’s application process will be more selective than in previous years, with only 5–10 care centers being accepted across all designations. Selection will be based on overall application strength and ability to improve access to expert PKD care in underserved geographic areas or underserved high-need communities.

Care Team Table

In the table below, indicate the members of your care team currently serving persons with PKD and their caregivers.

• For each specialty, indicate the name and email of the specialist, if they are at the institution (on campus) or if they are by referral only.
  • Core services/specialists marked with an asterisk (*) are required to be considered for this designation.
  • Partner Clinic applicants may not provide core services (*) by community referral.
  • Email addresses of all listed specialists are required. Contact information for each care team member noted above will be utilized in a Centers of Excellence listserv with opportunities for engagement and resources.
• If listing more than one specialist per row, please use same text box. Note any differences under the notes column.

Please provide a justification of ADPKD expertise for the Clinic Director(s), nephrologists, relevant nurse practitioners, physician assistants, other advanced practice providers, and support staff who treat or support ADPKD patients. Examples of expertise may include:

• Training under a recognized ADPKD expert
• Management of 50+ ADPKD patients per year
• Participation as an investigator in an ADPKD clinical study
• Management of ADPKD patients on tolvaptan
• ADPKD-specific education, outreach, or community engagement

Note: Justification must be provided for at least two nephrologists to ensure continuity in the event of a clinic director transition.

Note: This section is for PKD Foundation informational purposes only and will not be included in review criteria. Partner Clinics are not required to designate a patient naviagtor.

Patient navigator services may be provided collectively by one or more staff members, provided the following role requirements are met. 

Under supervision of the Clinic Director, serving in the patient navigator role will provide:

• Comprehensive coordination of care for patients with ADPKD and their families/caregivers
• Support to help eliminate barriers to timely care
• Facilitation of patient flow throughout the healthcare system
• Assistance with patient interactions and participation in clinical research opportunities
• Ongoing communication and coordination between patients, families, and providers
• Efforts to enhance patient and provider satisfaction
• Service as a primary point of contact for patients and families affected by ADPKD 

Partner Clinic designations will require annual progress reports to be delivered to the PKD Foundation by January 31 of each year. Centers are expected to engage with the network of PKD-familiar clinicians in the program, as well as the PKD patient community.

Mentorship Alliance 
A Center director and/or an appropriate delegate will be required to join a COE peer listserv aimed at providing PKD best practice feedback, guidance and case-based input to other clinicians serving PKD patients. The Center will be required to confirm, in the annual progress report, that guidance was provided to one or more Partner Clinic physicians to support high-quality care for patients with PKD. 

Professional Education and Awareness 
Institution’s Care Team Members will be required to participate in the following annual activities: 

• Annual PKD Centers of Excellence Conference (timing and format will vary from year to year).
• Institution staff peer-to-peer educational webinars (e.g. Case Study Discussions in ADPKD). Foundation will conduct at least two (2) of these webinars per year and Institution will be required to participate in at least one annually. 

Patient Advocacy and Awareness 
Institution’s Care Team Members will be required to participate in at least two patient advocacy or education activities and provide a report of these activities in the annual report that it provides to the Foundation. These may include:  

• Local Walk for PKD (complementary table will be provided) 
• Promotion of events being conducted by the local PKD Community 
• Hosting a patient facing community awareness or education meeting at your Institution (e.g. COE Patient Advisory Panel meeting)
• Hosting an educational tour of your research facility or labs 
• Participating as a faculty for patient facing webinars or PKDCON patient conference sessions 
• Offering meeting/support group space to local PKD Communities 
• Participating in events or initiatives aimed at raising awareness of PKD or addressing the needs of medically underserved patients in the community

ADPKD Registry 
I acknowledge and agree that our institution and/or care team is required to refer ADPKD patients to the PKD Foundation ADPKD Registry and to report on these referrals in the annual report submitted to the Foundation. 

Center of Excellence Review Process 
The applicant understands that if the COE Advisory Panel determines the application does not meet the criteria for Center of Excellence designation as set forth by the PKD Foundation, the clinic may be offered a Partner Clinic designation. The applicant will also receive constructive feedback to support a future reapplication in the next designation cycle.