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Updating Treatment Recommendations through Care Pathways

When patients are proactive in their care and use multiple sources, new methods of treatment and recommendation implementation is faster. However, incorporating new guidelines into patient education can often lag when patients only have one source of information. Unfortunately, Medicare patients face barriers to accessing these sources. This is where a Care Pathway is essential. As part of their individualized Care Pathway, all Connect Care Plus patients are routinely assessed by Care Coordinators. Therefore, changes in health recommendations can reach them faster.
The best role a Care Coordinator can play in the fight against CKD is that of prevention. The risk factors for developing CKD include a long list of chronic conditions that would qualify a patient for Chronic Care Management (ccp). The most common being diabetes and hypertension.(5) In fact, many these patients could already have CKD and be unaware of it.(6) Care Coordinators can reduce risk and slow progression by educating existing patients on the need to modify their diet, exercise regularly, take medications consistently, smoking cessation, and the increased risk for minorities.(4) Because Care Coordinators contact their patients monthly, they can deliver on-going patient education. Care Coordinators develop rapport with their patients and help them see the benefits of changing their habits and lifestyle.

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