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Coordination of Care and Care Transitions With Primary Care Clinicians, Specialty Palliative Care, and Hospice

Patients with chronic kidney disease typically have needs that cut across a range of services, including nephrology, other specialties, primary care, and palliative care. This chapter proposes a model of integrated supportive care from diagnosis to end of life that coordinates the efforts and maximizes the benefits of different healthcare teams. Supportive care teams can learn primary kidney supportive care skills to manage symptoms, provide emotional support, and facilitate conversations that focus on what matters most to patients and families. Applying best practices of care coordination, they can facilitate seamless transitions as the patient’s condition evolves.