| ESRD |
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The nature of ESRD; high costs in a relatively small number of patients, dictates a different kind of managed care approach from other chronic disease management programs. KidneyTel goes beyond the typical telephonic-only approach by utilizing a highly trained and experienced group of nurse care managers, supported by a state-of-the-art patient information system, and integrated care model with Telehealth Devices in the medical home gathering data from tailored questioned based on the individual's co-morbidities downloaded, to provide patient access 24 hours a day, seven days a week. KidneyTel also utilizes nephrologists as the patients‚ primary care providers. These board-certified experts are best able to manage the complex nature of ESRD. By investing in this high level of care, we prevent costly re-work that often happens with unnecessary hospitalizations and emergency department visits. KidneyTel’s patient-focused disease management model responds to the individual needs of each patient. KidneyTel’s nurse care managers use a patient evaluation and risk assessment tool that allows for patient stratification. Through this risk assessment process, we are able to dedicate 80% of the care manager’s time and resources to the most needy 20% of patients. KidneyTel’s follow-up system utilizing lab and treatment data, patient notification and close relationships with dialysis facilities allow the appropriate change in patient status to be tracked. KidneyTel’s nurse care managers facilitate the care and address the unique needs of each patient. They connect the patient with the necessary medical, social, dietary and pharmaceutical providers and help the patient comply with her/his health care plans. Our care managers also provide the patient with one-on-one educational guidance and informational materials. KidneyTel Medical Directors also play a key role in implementing our disease management plan. They are responsible for: |