Each identified member is assigned a registered nurse with extensive experience in renal disease. The VillageHealth nurse monitors the member's health status, facilitates compliance with physician-directed goals, communicates with the member's physicians and serves as a liaison and advocate for the member and his or her family. This nursing outreach may be by telephone or in person.
Patient assessment and care planning within the member's interdisciplinary team are coordinated by the nurse. This team includes the primary care physician, nephrologists and other care specialists.
Case management and care coordination are overseen by a panel of experienced nephrologists.
Member education includes, but is not limited to, the importance of taking medications as prescribed, management of comorbidities, management of lifestyle issues and identification of member-selected goals.
Adherence to national evidence-based protocols and guidelines helps prevent the development of other serious conditions.