In the U.S., chronic kidney disease (CKD) affects more than 1 in 7 adults and 1 in 3 adults is at risk for developing it, according to the National Kidney Foundation. Treating CKD focuses on slowing the progression of kidney damage — and that’s not a linear journey. People with CKD often have comorbidities, such as diabetes, hypertension and high cholesterol, as well as other conditions, including obesity, anemia, bone disease, high potassium, high calcium and fluid build-up. Managing these conditions requires an interdisciplinary team that is committed to whole-person care. We call this team the Kidney Heroes™.
The Kidney Heroes™ focus on the right intervention at the right time. If a patient isn’t progressing in a positive direction, the team tries to change that. Each person is trained to provide highly specialized care and understands the intricacies of kidney disease. Roles and staffing ratios are customizable based on individual market needs. The Kidney Heroes™ are:
Nurse Practitioners: The lead NP manages the clinical team, provides coaching, education and support, and works with partner providers.
Registered Nurse Care Manager: The RN helps patients navigate the complexities of the health system and coordinate patient care.
Care Coordinator: Scheduling appointments, supporting the RN care manager and nurse practitioners and communicating patient (and family) medical and non-medical concerns to the appropriate team members.
Medical Assistant: The MA supports the nurse practitioner in patient management, takes vital signs and obtains medical history and lab work.
Registered Dietitian: People with kidney disease require highly specialized diets and needs often change over time. RDs at Strive focus on medical nutrition therapy, which combines prevention, diagnosis and ongoing management.
Licensed Clinical Social Worker: A social worker helps manage psychosocial needs, provides behavioral and mental health counseling and crisis management, and refers patients to external providers and resources, as needed.
Clinical Pharmacist: The pharmacist is responsible for medication reconciliation and prescriptions. Day to day, this person reviews patient medication lists and helps patients understand the what, when and why behind their specific prescription.
Office Manager: The office manager ensures the clinic runs smoothly. This team member handles billing and insurance, supervises the medical assistant and manages clinic supplies.
The entire Kidney Heroes™ team acts as an extension of the nephrologist, who drives the overall management of a patient’s care. The team also includes a medical director, who is accountable for outcomes of the overall care model.
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Strive Health Dialysis