AddressProvides care coordination, case management and/or clinical management for patients with chronic kidney disease (CKD), including end stage kidney disease (ESKD) and renal replacement therapy (RRT) with primary focus on care coordination for general nephrology outpatient care of CKD population. Collaborates with internal and external providers to coordinate the plan of care and provide expertise in CKD/ESKD/RRT management and treatments including dialysis.
Essential Responsibilities:
- Acts as Care Coordinator for the care and follow up of patients in the nephrology specialty clinic and dialysis centers and including contracted transplant centers. Provides holistic proactive coordination care of chronic disease under Nephrologist supervision.
- Using standardized policies, procedures, and standing orders provides coordination of clinical care and education for symptoms, complications, labs, and medications by protocol.
- Navigation of complex care including arranges and monitors follow-up appointments, encourages members to follow prescribed course of care (e.g., drug therapy, physical therapy), and makes referrals to appropriate community/contracted services.
- Collaborates with patient, patient support, and interdisciplinary team members in assessing patients needs. Examples including scheduled follow up for self-care skill building; diet and other risk factor counseling; and medication management in the medical office setting. Assess patients readiness to learn and make lifestyle changes using motivational interviewing technique, teach and reinforce self-care skills.
- Provides patient education and consultation for patient and family members throughout disease progression.
- Coordinates care using the interdisciplinary care approach to providing continuity of care for CKD/ESKD patients. For example, coordinates with other programs such as chronic condition management, specialty care, surgical care, supportive care services and others to assure seamless transitions.
- Participate in performance improvement activities to enhance and monitor the quality and the level of care provided for patients with CKD/ESKD disease under nephrology care.
- Identifies and promotes improved innovative clinical practice based on new knowledge and research in field of specialization, using a broad scope of nursing expertise.
- Maintains up-to-date knowledge of current activities in Nephrology, CKD/ESKD/RRT care.
- Ensures that accurate clinical information and data is maintained.
- Performs other Nephrology specific duties to support CKD and ESKD patient population needs.
