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Diane

CKD Chronic Care

Diane is designed to perform a weekly check in on how a patient is managing their Chronic Kidney Disease and address any gaps in care. She focuses on a number of things such as blood pressure, lab results, medication adherence and diet. See the detailed list below.

Style:  Engaging

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what they thought about Diane’s performance

CKD Chronic Care Call Checklist:

  • Symptoms Review - Ask if the patient is experiencing any new or previously reported symptoms, including symptoms commonly associated with CKD (back pain, reduced urine output, etc…).

  • Blood Sugar/Pressure Check - Review blood pressure and blood sugar; note if it is above, within, or below the reference range.

  • Lab Values - Communicate the patient’s lab results and provide the reference ranges relevant to each test. Review current and prior results. Explain the purpose of commonly ordered lab tests (e.g., BUN, Creatinine, eGFR, Hemoglobin, Urine Albumin, etc.).

  • Prescription Medication and OTC Drugs - Review the patient's medications and confirm they understand their prescription and are taking them as prescribed. Ask if the patient is taking any OTC medications or supplements; provide relevant information. (Rachel can check if reported consumption is within the recommended range for OTC drugs and supplements, and can check if any OTC drug or supplement is contraindicated for any of the patient’s prescribed medication or EHR.)

  • Lifestyle and Nutrition Management - Provide encouragement and suggestions to help the patient follow a potassium and/or phosphorus restricted diet, maintain a healthy weight, and avoid smoking and excessive alcohol consumption. Help the patient identify CKD friendly food recipes and recommend appropriate menu items from restaurants. (Rachel is able to provide education on food labels, top categories of sodium heavy foods, along with meal strategies, such as small frequent meals as necessary.)

  • Checks on Durable Medical Equipment - Ask if the patient has any questions about their durable medical devices (CGM, Insulin Pumps, etc).

★ Special Features

  • Health System-Specific Policies - Rachel can be instructed to follow health system-specific instructions and affiliated practices, such as cardiac physiology services, cardiac nutritionist and rehab programs.

  • Provider Preferences - Rachel can be instructed to follow provider-specific preferences for discharge care, such as nutrition suggestions, fluid restrictions and exercise activity limitations.

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