Holistic and personalized patient care in partnership with leading nephrologists and PCPs
Our Total Patient Care Service is comprised of four components:
- Care Management Program: Interventions focus on slowing disease progression through early detection, improved access to care, patient education, comorbidity and medication management, and addressing social determinants of health.
- Transitions Management Program: Interventions focus on managing any acute transition and the transition to ESKD.
- Medical Care Extension Program: Interventions focus on addressing gaps in medical care.
- Clinical Documentation Program: Interventions focus on closing patient quality and documentation gaps.
Serving CKD & ESKD Patients
Our omni-channel approach directly engages patients telephonically, by mail, digitally, and in person at their doctor’s office, in their dialysis clinic, and at their home. We deploy evidence-based, interdisciplinary interventions to patients based on their current risk level and existing support, in a personalized way that drives immediate value. These programs are available to all patients regardless of their provider.
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Empowering Providers, Elevating Care
Our Provider Enablement Service equips providers with the tools, practice resources, and support to drive sustainable change. We create deep alignment between our care team and network physicians through:
- Aligned Physician Economics: shared savings program and value-based care performance incentives
- Embedded Clinical Resources: Renal Care Coordinators embedded in practices focused on CKD value-based care interventions, including transplant referral and tracking
- Quality and Clinical Documentation Support: assist with revenue growth, improve clinical outcomes, and reduce medical spend
- Customized Reporting & Insights: actionable data to optimize practice operations
- Interwell Learning & Resources: tailored training, tools, and proprietary patient education courses ·
- Acumen® Epic®: our nephrology-specific EHR drives workflow changes to enhance patient care and provider value-based care performance
By equipping providers with the right incentives, technology, and support, Interwell empowers providers to improve patient outcomes and practice performance.