Disease Management
The team supports the treating providerโs care plan through patient education, monitoring follow-up, care-gap identification, comorbidity management, and coordination across nephrology, primary care, cardiology, endocrinology, and other involved clinicians.
Care is tailored to disease stage, comorbidities, recent utilization, and the patientโs ability to participate. Education may include the importance of ordered laboratory testing, blood pressure monitoring, symptom reporting, medication adherence, and following nutrition guidance from the treating clinical team.
