In the U.S., chronic kidney disease (CKD) affects more than 1 in 7 adults and 1 in 3 adults is at risk for developing it, according to the National Kidney Foundation. Treating CKD focuses on slowing the progression of kidney damage — and that’s not a linear journey.  

People with CKD often have comorbidities, such as diabetes, hypertension and high cholesterol, as well as other conditions, including obesity, anemia, bone disease, high potassium, high calcium and fluid build-up. Managing these conditions requires an interdisciplinary team that is committed to whole-person care. Here at Strive Health, we call this team the Kidney Heroes™.

Strive’s distinctive care model is anchored by the Kidney Heroes™, who are empowered with groundbreaking technology and the ability to deliver care where and when it’s needed — at primary care physician (PCP) or nephrology offices, at the hospital, in the home or at Strive Care Centers, which provide in-center dialysis, home dialysis training, education and disease management.

“Patients with CKD are dealing with a lot of complexities in their care, and we want to relieve the burden as much as possible,” said Dr. Shika Pappoe, nephrologist and Strive Health’s Chief Medical Officer. “The Kidney Heroes™ embed empathetically and deeply into patients’ lives and help them on their journey to achieve greater health outcomes. The team meets patients where they are and works together to coordinate care so patients don’t have to.”

Meet the Kidney Heroes™

The Kidney Heroes™ focus on the right intervention at the right time. If a patient isn’t progressing in a positive direction, the team tries to change that. Each person is trained to provide highly specialized care and understands the intricacies of kidney disease.  

Team members work together to provide the Strive care model, and roles and staffing ratios are customizable based on individual market needs. The Kidney Heroes™ are:

• Nurse Practitioners: The lead NP manages the clinical team, provides coaching, education and support, and works with partner providers. Supporting NPs provide clinical care to patients, care coordination across the team, triaging, medication updates and more.
• Registered Nurse Care Manager: The RN helps patients navigate the complexities of the health system and coordinate patient care. This includes educating patients, calling partners for updated lab results, reconciling medications and managing patient appointments and follow-ups.
• Care Coordinator: Scheduling appointments, supporting the RN care manager and nurse practitioners and communicating patient (and family) medical and non-medical concerns to the appropriate team members are the primary responsibilities of the care coordinator.‍
• Medical Assistant: The MA supports the nurse practitioner in patient management, takes vital signs and obtains medical history and lab work. Like care coordinators, medical assistants also help with patient scheduling. ‍
• Registered Dietitian: People with kidney disease require highly specialized diets and needs often change over time. RDs at Strive focus on medical nutrition therapy, which combines prevention, diagnosis and ongoing management. They educate patients on diet and nutrition, provide resources and prescribe a kidney-friendly diet specific to a patient’s needs. ‍
• Licensed Clinical Social Worker: Patients and their families often need emotional, financial, career and lifestyle adjustment support. A social worker helps manage psychosocial needs, provides behavioral and mental health counseling and crisis management, and refers patients to external providers and resources, as needed.   ‍
• Clinical Pharmacist: The pharmacist is responsible for medication reconciliation and prescriptions. Day to day, this person reviews patient medication lists and helps patients understand the what, when and why behind their specific prescription.   ‍
• Office Manager: At Strive Care Centers, the office manager ensures the clinic runs smoothly. This team member handles billing and insurance, supervises the medical assistant and manages clinic supplies.    

The entire Kidney Heroes™ team acts as an extension of the nephrologist, who drives the overall management of a patient’s care. The team also includes a medical director, who is accountable for outcomes of the overall care model.  

“Altogether the medical director, nephrologist and Kidney Heroes™ deliver high-touch care that’s specific to each patient’s individual needs,” said Voranan Pongquan, Director of Care Model Design and Innovation at Strive Health. “This approach can help patients delay the progression of kidney disease, stay out of the emergency room and experience better quality of life overall.”

To learn more about the Kidney Heroes™ and how they serve the patient care journey, complete our contact form.

‍