Care Management Program

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

Let's Get Started

Skip to content