Care Coordination

Georgia Pines Kidney Care Alliance ESCO beneficiaries will experience individually tailored care in order to improve health outcomes. Our services include the following:

  • Coordination of care transitions
  • Coordination of vascular access placement and care coordination of community-based services, such as psychosocial health
  • Medication therapy management
  • Health care system navigation

Georgia Pines Kidney Care Alliance Care Coordinators

  • Lisa Farrar, RN, CDN
  • Julie Mack, RN, BSN
  • Tiffany Mike, RN, BSN
  • Phillis Wiggins, LPN
  • Sonia Hughes, LPN
  • Brittney Thomas, RN
  • Natalie Wilson, RN

Patient-Centered Education

Kidney disease education begins during the early stages of chronic kidney disease (CKD) and extends through the transition from dialysis to an alternative therapy or to the end of life.

We focus on educating patients during each stage of their disease and supporting them in making the health care decisions that work best for them. We also include family members and caregivers in beneficiary education.

Care Integration

People with kidney disease have complex care needs that require the expertise of multiple clinical specialists and community health providers. Our ESCO model of care integrates nephrologists, vascular surgeons, home health, palliative and hospice care providers and others in order to form a more seamless network of clinicians who can coordinate services and provide a superior level of care.

Our model of care relies on various health information technology (HIT) tools that support/aid in the delivery and coordination of care. Participating providers and community partners benefit from improved access to health information via a robust data integration platform that provides access to a comprehensive patient medical record at the point of care.

Care coordinators benefit from a kidney disease-specific care management tool. Pharmacists have access to a medication therapy management platform that improves medication management and reduces mediation related problems.