Renal Care Patient Navigator

The CKD Patient Navigator is responsible for providing care coordinationand support to patients with chronic kidney disease (CKD) across various stages of the disease. This role serves as a liaison between patients, families, nephrologists, primary care providers, and the interdisciplinary healthcare team to optimize patient outcomes, promote self-management, and ensure seamless transitions of care. Leveraging an integrated technology platform, you are complemented by an entire interdisciplinary team from Nephrology Associates and its partner Evergreen Nephrology including Nurse Practitioners, Nurse Care Managers, Care Coordinators, RN Educator, Dieticians, Pharmacists, Licensed Clinical Social Workers, and Psychiatrists.

You will take the lead on identifying care gaps and navigating the patient through their CKD to ESKD journey in collaboration with a Care Coordinator, RN Educator, and the primary Nephrologist. You will play an essential role in helping patients achieve their goals through timely and proactive care planning toward a smooth

outpatient dialysis start with a permanent access or a care pathway of the patient’s choice driven by patient education and care team support.

PRIMARY FUNCTIONS

· Patient Identification and monitoring: Maintain a spreadsheet database including patients with CKD who are at risk of progressing to dialysis. Using the practice EMR, continually update the spreadsheet with important information and milestones that need to be completed for the patient to have a smooth transition into dialysis. Keep track of every patient who starts dialysis noting whether they start “optimally” or “suboptimally” (optimal means they start with permanent dialysis access without need for hospitalization.

· Care Coordination & Navigation: Assess for care gaps in milestones and other quality measures, and support coordinating care to close gaps. This will entail meeting/communicating with the patient’s nephrologist regularly about their panel of patients to ensure decisions are made to close those gaps. Facilitate smooth transitions of care and end to end navigation for patients with CKD progressing to ESKD. Collaborate with the Evergreen Nephrology interdisciplinary team and patient’s Nephrologist to develop and implement care plans that address the unique needs of patients, ensuring seamless transition from CKD to ESKD plan of care. Assist in coordinating referrals for transplant evaluation, dialysis treatment options education, dialysis access placement, and home dialysis training as needed. Assist with early dialysis access planning (arteriovenous fistula/graft placement or peritoneal catheter insertion) in collaboration with vascular surgeons and nephrologists.

· Disease Progression and Monitoring: Understand and trend laboratory values to assess CKD progression. Recognize and escalate signs of worsening kidney function, electrolyte imbalances, fluid overload, and metabolic disturbances. Social Determinants of Health: Identify barriers to care and connect patients with Evergreen Nephrology interdisciplinary team members for appropriate resources, including financial assistance programs, transportation, and community support services such as housing assistance, transportation, food security, and community support programs.

· Collaborative Communication: Maintain open lines of communication with patients, families, caregivers, and healthcare teams to ensure coordinated care and address any issues that may arise during the care process. Refer all patients choosing medical management without dialysis to Evergreen Nephrology Compassionate Care Program for help in establishing goals of care and advanced care planning.

· Documentation and Reporting: Ensure accurate and timely documentation of patient interactions in the EMR and keep accurate data on all CKD patients under care navigation in the spreadsheet or database. Manage a process to ensure accurate and timely completion of the CMS 2728 form that is used for every new patient starting dialysis.

· Education and Empowerment: Provide comprehensive education to patients and families on CKD progression, treatment options, medication adherence, lifestyle modifications, and dialysis modalities.

Empower patients to participate in self-management strategies to slow CKD progression and improve quality of life.

· Other duties as assigned, including cross coverage between markets when needed