Provide palliative social work support to patients with advanced kidney disease, including goals of care conversations, behavioral health interventions, and advance care planning.
Collaborate with interdisciplinary teams and external providers to develop individualized care plans addressing physical, emotional, and spiritual needs.
Educate patients and families on community resources and hospice services, advocating for patient needs and preferences.
Manage the healthcare journey of kidney disease patients in the Compassionate Care Program, focusing on advance care planning and goals of care discussions.
Collaborate with physicians and interdisciplinary teams to coordinate transitions to hospice or ongoing care based on patient preferences.
Educate internal and external partners on identifying and referring patients to the program.
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic approach. As a startup, it is committed to improving patient outcomes and quality of life with an innovative and evolving culture.
Lead internal case rounds to ensure care coordination and appropriate care plan development.
Coordinate with network and longitudinal care providers to support serious illness conversations.
Monitor network data and metrics to drive quality improvement and cost-effectiveness.
Tuesday Health is a value-based palliative care provider group dedicated to transforming serious illness and end-of-life care. They deliver goal-centered care with interdisciplinary teams to reduce avoidable hospitalizations and improve quality of life.
Conduct comprehensive psychosocial assessments and provide therapeutic interventions for cancer patients and their families.
Facilitate crisis intervention, resource linkage, and care coordination with healthcare teams.
Lead support groups and advocate for patients' needs with insurance companies and providers.
Thyme Care is a market-leading value-based oncology care enabler that partners with health plans, providers, and employers to improve outcomes and lower costs for people with cancer. As a tech-native organization, it combines high-touch human support with AI to strengthen the care experience, fostering a culture of inclusion.