Rogosin Kidney Care Alliance, LLC
End-Stage Renal Disease Seamless Care Organization
People with kidney disease have complex care needs that require the expertise of multiple specialists and community health providers. RKCA's model of care begins with an interdisciplinary team – comprised of the principal care nephrologist, vascular surgeon, interventional radiologist, nurse practitioner, social worker, nutritionist, primary care nurse and care manager – who all work together collectively to focus on patient needs and develop care plans to improve health outcomes that are tailored to the individual. Coordination of patient care extends beyond the inpatient dialysis center to address factors in a patient's home and family life, as well as to provide smooth transitions to palliative and hospice care when medically appropriate. In addition, through longstanding relationships with cardiology, endocrinology, gastroenterology and podiatry practices, RKCA is able to coordinate care with multiple specialists.
Our services include the following:
RKCA is committed to a patient-centered approach that facilitates shared and informed decision-making throughout the continuum of kidney disease. Kidney disease education begins during the early stages of chronic kidney disease and extends to the transition from dialysis to an alternative renal replacement therapy or to the end of life. Through an interdisciplinary care team approach – including the nephrologist, care manager, social worker, nutritionist, nurse practitioner, and primary care nurse – RKCA will educate patients and their caregivers at multiple points of care.
Through a valuable relationship with visiting nurse services, patient education efforts will also extend into the home environment to enhance compliance with treatment regimens. In addition, by partnering with Calvary Hospital, a premier provider of end-of–life care, patients will receive critical support and guidance to enable a smooth transition to palliative care and hospice when medically appropriate.
RCKA utilizes a multifaceted, data-driven approach to improving the quality of care, patient outcomes and patient satisfaction. Providers have access to near real-time feedback at both the patient and population management levels via a robust data integration platform and electronic medical record at the point of care. Care coordinators benefit from a kidney disease-specific care management tool that helps to identify at risk patients. Pharmacists have access to a medication therapy management (MTM) platform that improves medication management and reduces mediation related problems. The MTM platform also feeds into a patient medication therapy management program that is designed to improve compliance and outcomes, as well as reduce the risk of adverse events. Through these QAPI measures, RKCA is able to continuously monitor the effectiveness of interventions, proactively adapt care regimens and assess provider performance. In addition, RKCA evaluates the impact of interventions and implements strategies to improve the patient experience through multiple patient satisfaction tools and surveys.
The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document.
Last Revised 12/1/2017