Because ESRD results in high costs in a relatively small number of patients, it dictates a different kind of managed care approach from other chronic integrated care management programs. We go beyond the typical telephonic-only approach by using a highly trained and experienced group of nurse care managers supported by a state-of-the-art patient information system to provide patient access 24-hours a day, seven days a week. Fresenius Health Partners also uses 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.
Our patient-focused integrated care management model responds to the individual needs of each patient. Our nurse care managers use a patient evaluation and risk assessment tool that allows for patient stratification.
Through the risk assessment process, we are able to focus on each individual patient's comorbidities and risk areas. And, our care managers can allocate their time effectively to accomplish outcome improvement goals with their patients.
Our clinical data system provides aggregation of data from the dialysis clinic, the nephrologist, labs, and our proprietary health home monitoring system to constantly update patient health status and target our nurses' efforts and follow-up with patients and their providers.
Our 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.
Our Medical Directors also play a key role in implementing our integrated care management plan. They are responsible for:
- orienting the health plan medical management and provider network to our program
- interacting with nephrologists on high-risk cases
- reviewing high risk cases with care mangers
- developing and/or reviewing clinical practice guidelines and algorithms
- leading local quality committees
- presenting quarterly reports to health plans
