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OUR SERVICES
High Risk Patient Care
KSOSN has designed and initiated a process of managing the care of high-risk patients by using a number of different tools.
The High-Risk care team includes our physicians, nurse practitioners, physician assistants, medical assistants, RN educator and care navigators.
A patient may be considered high risk if the patient:
- Is managing multiple comorbidities
- Has a prior hospitalization within the last year
- Had frequent ER visits within the past six months
- Has poor social support, lack of transportation, or financial barriers to healthcare
To help prevent future hospitalizations and ER visits, KSOSN is focusing on:
- Referring to specialists who can see patients promptly and will consistently communicate their finding back to our office
- Educating the patient and caregivers on disease-specific warning signs
- Providing Kidney Education
- Advising patients when to call for help and whom to call
- Advising patients when to use emergency care
- Linking patients to community resources
- Completing medication reconciliations
- Scheduling post-hospital office visits
- Offering Telemedicine visits
- Ensuring that patients understand the necessity of self-management between appointments
