Inside Interwell How ESKD Care Coordinators Assist in Patients Lives
The Interwell Health end-stage kidney disease (ESKD) care coordination team exemplifies compassion, persistence, and critical thinking as they navigate complex healthcare systems, build personal connections, and transform the lives of patients living with ESKD.
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For patients with end-stage kidney disease (ESKD), navigating the healthcare system can feel like a full-time job. Beyond the physical and emotional toll of their condition, they must deal with multiple doctor appointments, dialysis treatment several times a week, insurance paperwork, and logistical challenges. To alleviate this strain, Interwell Health’s ESKD care coordinators serve as helpful guides and advocates, often acting as a crucial lifeline for these patients.
The ESKD care coordination team, made up of nearly a dozen employees, operates on a foundation of collaboration, critical thinking, and personal connection to help improve the patient experience one individual at a time. They connect patients to providers, schedule appointments, and help patients navigate complex health systems. They assist with finding durable medical equipment (DME) options, explore home health options, and research community resources when insurance doesn't cover a need. When patients have access to these resources, they often have reduced hospitalizations, lowering their total cost of care.
According to the care team, many patients with ESKD express feeling unheard or overwhelmed. The coordinators make it their mission to change that. Marc Hilburn, a senior care coordinator, notes the satisfaction of calling a patient who recognizes his voice instantly. By genuinely listening, the team often uncovers the true story behind each patient's needs, which can be far more complex than the initial request suggests.
Christine Klemm, a senior care coordinator, explains that breaking down complex medical terminology and speaking to patients with respect is crucial. "We're that compassionate voice on the other end of the phone," she says. "Developing that relationship and getting them to trust us, that's a big part of our role." This trust empowers patients, helping them become active partners in their own care.
Critical thinking in a complex system
No two patients have the same needs, medical history, or insurance, so every individual requires creative, out-of-the-box thinking and persistence from the team. They regularly reach out to city, county, state, and community resources to help get patients what they need.
For example, one patient’s daughter was having trouble obtaining a hospital bed for her mother. She explained her mother could not sleep well and was experiencing breathing problems while lying down and needed a hospital bed to prop her up. The daughter expressed to the ESKD care coordinator that she could not afford one, so the coordinator located a community resource near her and was able to get her one free of charge. This equated to major savings for the patient and her family, as hospital beds can run from hundreds to thousands of dollars.
"We're that compassionate voice on the other end of the phone. Developing that relationship and getting [patients] to trust us, that's a big part of our role."
Additionally, the team often leans on each other for ideas and support. When Christine needed to find a medical group home for a patient with complex needs, she started making calls. And while she did find quite a few options, they did not fully meet the patient’s needs. Christine collaborated with fellow teammate Kaitlyn Michiels, a care coordination preceptor, to find a proper skilled facility for the patient.
Going above and beyond is standard practice
While many people may associate “going above and beyond” as extra work, the ESKD care coordination team sees it as a part of their culture and everyday routine. “I think a lot of ‘going above and beyond’ is a part of who we are because as a group; we're very determined and passionate about helping other people,” shares Morgan Vogel, a senior care coordinator. “Our entire job is just us doing whatever we can to help our members.”
The impact of this approach is profound. Patients and their caregivers, often exhausted and in need of support, express immense gratitude. They are thankful for the hours the team spends on the phone with insurance companies, pursuing potential DME and home health options, and just listening to their needs.
The ESKD care coordination team understands the challenges patients face each day and the importance of every small victory. They provide not only solutions but also hope, proving that compassionate, persistent care can truly change lives.