Blog Post

Value-based Kidney Care: The Care Navigator’s Perspective


In this blog, Healthmap Care Navigator Tracy L. Sherwin, RN, BSN, BHS, shares insights gained from her experience helping chronic kidney disease patients engage in their treatment.


Part 1: First Contact

At Healthmap Solutions, we are committed to high-quality, member-centric care. One of the distinguishing features of the Healthmap approach to kidney population health management is our specialized, multidisciplinary team of Care Navigators who provide direct, ongoing support to the patient. Each eligible patient in our Kidney Health Management (KHM) program is assigned a personal Care Navigator (CN) to engage, encourage, and empower patients in their disease management journey.

The CN is the patient’s clinical coach outside of the physician’s office. As the coach, the CN is able to provide any information the patient needs to enhance their understanding of their disease, including the clinical, social, and behavioral impacts of this chronic condition, and thus be able to work more closely and effectively with their doctors throughout the disease condition.

Starting the Process

Let us introduce Tracy L. Sherwin, RN, BSN, BHS. Tracy is a 10-year veteran with Healthmap and one of our most experienced CNs. We asked Tracy to give us her perspective on the CN’s role, along with insights into the techniques she uses to engage patients with expertise and empathy.

“My process starts when I receive a secure notification that a patient has been assigned to our KHM program,” she said. “At this point I receive the patient’s contact information and supporting clinical information, to include medicines, chronic conditions, and social barriers, to name a few. This important information provides me with the patient’s history and what they may already know, so I can really focus in on what they don’t know.”

Tracy said that her goal in the first call with a patient is to establish a rapport. The CN acts as a patient advocate and builds a relationship over time with the patient.

“On the initial call, I am really just trying to engage with the patient and assess how they want to interact with us,” she explained. “I really want them to feel comfortable on this initial call—otherwise, they may not be willing to answer the phone the next time.

“One of the ways I establish a friendly relationship is to research where the member lives and familiarize myself with the local area. Often, I can say, ‘Hey, I know where that is, it’s so pretty over there!’ I always try to establish the call from a personal perspective so as to disarm the patient and not sound so programmed.”

The Importance of Listening

Healthmap has established standards and skills for CNs when working with patients. However, Tracy believes that one of her most important skills is listening. She said it’s important to listen to the member, build rapport, and initiate an authentic conversation that will facilitate two-way, honest communication with the patients.

“If I only get limited time on the phone with the patient, I want to make sure that the patient views the time as valuable,” she said. “By defining value for my patients, I know they’ll pick up the phone next time because I’m not just robotically asking them questions. You really want to make it informative and have them enjoy talking to you. I try to talk to them the way I’d talk to my own family, and I think they can feel that.”

In some instances, Tracy said, the patient may not even want to talk about kidney disease during that first call.

“One of the most difficult situations I deal with is patients not knowing how serious their condition is,” she explained. “Or maybe they are in denial because they had an aunt who died while on dialysis, and they think this is ultimately their outcome and do not want to address it head-on.

“Other times, they may just have something else pressing on their mind,” she continued. “Today, for instance, I had a patient who just wanted to talk about getting their insulin. While insulin management was not the planned primary discussion for our call, having diabetes is a key co-morbidity associated with kidney disease, and not having the right meds available was causing anxiety for the patient, so appropriately, we worked on that for the majority of the call.”

And Once the Rapport Is Established?

Tracy and our other CNs suggest a defined frequency and cadence of calls that meet the needs of the patient’s schedule. “The frequency of patient engagement is based on the level of clinical intensity and needs. However, the final cadence of the interaction should be the patient’s decision,” Tracy said.

On the first call, Tracy asks the patient how often they want to be contacted: once a month, twice a month? Tracy said that being flexible to meet the needs of the patients, especially during the first few months of engagement, has allowed her to develop a strong rapport. ”Whatever my patient feels comfortable with, is what I try to accommodate,” she said, “and this seems to have been what works best for my patients.

“I also send out to the patient pertinent information identified from our phone calls. I'm kind of old-school in that I think it’s more helpful for them to have a hard copy they can refer to. For example, I can send information on eating habits as a diabetic, or how to take your blood pressure correctly.”

The Big Three

We asked Tracy about the three common care issues she deals with in working with her patients. Tracy said that she most often addresses what she refers to as “my big three,” which are co-morbidities, nutrition, and medications.

CNs manage the patients holistically, so all of their co-morbidities, social determinants of health(SDoH), behavioral health needs, and support systems are important aspects of care.

“One of the things I talk with patients about most often is how their other chronic conditions, like diabetes or hypertension, affect their kidney health,” she said. “They often don’t understand or haven’t been told how one relates to the other.

“Another issue is diet and nutrition,” she continued. For example, “A lot of people don’t realize that four steaks in a week is way too much protein consumption for someone with kidney disease. I provide them with good guidelines, as well as connect them with a dietitian who can explore diets and recipes with them.

“The third is medications. Most of my patients don’t know what certain medications can do to their kidneys,” Tracy said. “Our kidneys are filtering all the time, and some of the things they routinely take may be nephrotoxic in the long term. They may not be aware of what a common pain reliever can do to their kidneys. Again, they probably haven’t been told.”

The Social Order

When interacting with her patients, Tracy will gently probe to uncover SDoH needs, which are the conditions where a patient lives, learns, works, plays, and worships that can affect their health. CNs utilize Healthmap-employed Licensed Social Workers to assist with patients’ SDoH needs.

“In the first call, I like to mention that we have other care services available to help,” she said. “I start out by saying, you may not need this now, but just keep it in mind for the future. I point out that we offer transportation services to get them to their doctor’s office or to have labs drawn, for example. If the issue is food insecurity, I can provide guidance to local food banks and churches to offer support.”

The Coaching Side

“Some patients want as much information as possible and they are more than ready to be engaged in our program. That’s what makes my job fulfilling,” Tracy said. “One of my patients takes notes on everything we speak about because she finds it so interesting and helpful, and she shares these notes with her doctor.”

She was also open to coaching, as Tracy related.

“She wasn’t drinking enough water. I think we can all relate to that, right? I know I don’t drink enough water. So, I suggested she do what I do and keep a nice insulated, stainless-steel tumbler handy. She said, ‘I already have plenty of those, that won’t work.’ So, I suggested going online and looking for a metered water bottle. ‘Or if you really want to get into this, get a smart bottle with an alarm to remind you to drink,’ I said.

“So, she got a water bottle that lights up and keeps track of how much water she’s drinking. And she saw her eGFR increase from 42 to 47. That’s huge! And she said to her nephrologist, ‘That’s my nurse Tracy.’ So, I was able to help her find something she could use and enjoy which helped her be successful.

“If you make yourself relatable, they feel like you’re not just ‘this nurse’ or ‘this health professional’ who is judging them. I say this to all the people I train: If you go out there just with questions—bam, bam, bam—they’re not going to pick up the phone again.

“My attitude is, I'm going to find something that will enable us to work together. Because then, we’ll have a nice, long health management relationship for their kidneys,” Tracy added.