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

To schedule an appointment or to speak with our care team, please call our office at 702-877-1887.