for what’s

effort to increase education and care for patients with kidney disease – and doing so should lower costs.

There are a number of healthcare companies attempting to provide some of these services via care management systems run primarily by nurses and other support staff, often remotely, and rarely in partnership with a patient’s physician.

As we all know, Value-Based care is the popular phrase for this delivery model, but I prefer a less catchy, but more accurate phrase: Physician-driven, patient-centered care. It is physician-driven because nephrologists will be taking responsibility and financial risk for every facet of their patients’ care. It is patient-centered because every medical decision we make in partnership with our patients will be guided only by what is best for those individual patients. I would like to think that all of us as physicians have always made decisions for patients based only on what is best for them – but in a fee-for-service system, we must all recognize that distorted incentives exist that can affect care.

Along with 16 other practices nationwide, our practice has partnered with Evergreen Nephrology to provide physiciandriven patient-centered care to our patients.

Over the next few years, we expect to provide these expanded services to a majority of our ESKD and advanced CKD patients. We will be doing home visits, providing mental health support services where needed, addressing transportation limitations, education and patient engagement, food insecurity, early support and education for transplant services, medication review and education, just to name a few facets of care. Using data analytics, we will access all of a patient’s available electronic health information and leverage that predictive modeling to identify and intervene on the highest-risk patients to make their lives better. We will be focused on disease prevention and stabilization to reduce the number of patients who are forced to start dialysis or undergo transplantation. For those who worsen despite our best efforts, we will be helping to coordinate kidney transplantation when possible – hopefully before a patient ever needs dialysis. For those who are forced to start dialysis, we will be focused on Home Dialysis modalities which have equivalent outcomes to standard incenter dialysis, but much better quality of life scores at a lower overall cost.

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