Care Management Program
LIST OF SERVICES
General Chronic Care Management Services
- Kidney Disease Education
- Medication review, care plan development, follow up
- Addressing Social Determinants of Health
Remote Patient Monitoring
- Blood pressure
- Weight
- Heart rate
- Sp02
- Blood glucose
High-Risk CKD Program
- Risk stratification
- Medication review
- Care Plan development
- Regular check-ins with patients
Medication Assistance
- Expedited preauthorization assistance
- Free 1-month supply for all new prescriptions
- Free medication samples
- Assistance with obtaining high-copay medications at low copay or no cost
Transitional Care Management
- Transitional care management visit
- Care plan development and implementation
- Medication reconciliation
- Follow up referrals
Dialysis Preparation Services
- Dialysis Education
- Modality Selection
- Home PD/HHD Training
- Referral for access placement
- Access placement in outpatient setting
- Coordination of medical clearance appointments
Renal Transplant Services
- Transplant referrals
- Coordination of medical clearances for renal transplant
- Care coordination
Medical Nutritional Therapy
- General CKD/ESRD dietary education
- Personalized dietary plan developed with a Renal Dietitian
ER Diversion
- Telephonic triage by ER physicians
- ER physicians on call 24/7 to evaluate and assist patients
- Care team network in place to assist with patient needs, concerns, requests, SDOH
CARE MANAGEMENT TEAM
Kidney Care
Done Better
Join our Community
of Renal Specialists