Strive’s Patient-Centric Care Model Redefines the Kidney Care Experience

Author : Strive Health

Picture the patient who shows up to the emergency room fatigued, confused, out of breath and without an appetite. Until this visit, they were completely unaware they have kidney disease. Now, they are in need of urgent kidney replacement therapy. Though grateful for answers, they may be overwhelmed and confused by the many important medical decisions they face.

They may feel confused about the medical jargon they’re hearing for the first time, as well as the various treatment options, which can have implications on short-term and long-term health. The patient may feel pressured to make quick decisions and may be uncertain about the impact certain treatment pathways could have on their work and personal life.

Beyond the clinical experience, imagine the financial impacts of hospital admission, ongoing care and the potential complications and costs associated with unplanned dialysis starts.

The fact is one in three U.S. adults are at risk for chronic kidney disease (CKD). More than 60% of kidney failures occur without warning and only 40% of CKD patients see a nephrologist before their kidneys fail. Strive aims to change these statistics with a patient-centric Care Model focused on early detection, education and empowerment.

“Kidney disease care should start well before someone reaches end-stage,” said Dr. Shika Pappoe, nephrologist and Strive’s Chief Medical Officer. “And, at Strive, we believe care should address the whole person — not just their diagnosis. We define patient-centric care as working ‘with’ patients and their families rather than just doing care ‘to’ or ‘for’ them. Ultimately, Strive patients determine how they will participate in care and decision-making.”

How Strive’s Care Model Is Set Up

Strive works with health systems, medical groups, payors and nephrologists. But no matter the partner, the focus is the same: patients.

The team at Strive operates as an extension of a partner’s team, helping them better care for patients using a value-based approach. Value-based care has been shown to improve outcomes for patients while rewarding healthcare providers with incentive payments for the quality of care they provide. Improving patient experience and health outcomes is foundational to Strive.

Strive believes a successful Care Model must include three core components:

  1. High-touch care provided by a robust team of clinical and non-clinical personnel.
  1. A sophisticated technology platform capable of ingesting data from across the healthcare system — and using it to drive actionable insights in real-time.
  1. Comprehensive renal replacement therapy focused on pre-emptive kidney transplants and home dialysis where transplants are not possible.

The combination of these three components allows for an end-to-end solution for patients that spans early CKD identification through renal replacement therapy.

What Makes Strive Different?

Strive’s distinctive Care Model includes:

  • Putting patients first: Strive is creating a unified patient experience that is rooted in:  
  • Engaging and supporting clinicians to be their best selves to serve patients, families and communities. Strive empowers clinicians through continuous education, training and support for a rewarding provider experience.
  • Delivering technology patients interact with that improves their overall experience and care. Strive engages patients remotely with telehealth tools and resources for education to provide additional channels for patients to engage in a way that is convenient and helpful for them.
  • Listening to patients to inform continuous improvement. “Although we’re confident that our model delivers a differentiated patient experience, we’re always looking for ways to improve by collaborating with and hearing directly from patients,” said Emmie Watson, Strive’s Patient Experience Lead. Strive’s Patient Advisory Board regularly brings together patients, their family members and Strive staff to hear directly from patients and then incorporate their voice into the Strive Care Model. Additionally, Strive’s interdisciplinary, kidney-specialized care teams continuously evaluate and improve the patient experience through frequent patient touch points and experience surveys, sharing learnings among Strive’s teams locally and nationally. These surveys evaluate access to and quality of patient care, including choice of providers and choice in care settings. This feedback and performance data is also shared on a timely basis with participating providers.
  • Creating spaces — both in-person and virtual — where patients feel safe and cared for. Strive engages patients at a Strive Care Center, a physician’s office, a hospital, an outpatient healthcare facility or in their home. All clinicians receive patient experience training when they onboard with Strive that includes understanding social determinants of health, disparities and the importance of whole-person care. More importantly, the information gathered helps inform clinicians on the care and services that are tailored to the patient. Strive’s work focusing on education of staff around diversity, equity and inclusion enables Strive’s Kidney Heroes™ to provide safe spaces at the point of care and eliminate the burdens patients face.
  • Building relationships to create lasting support systems that meet patients where they are and create the foundation for care. Strive’s Care Model is built on the belief that an exceptionally strong patient-clinician relationship benefits the patient physically and emotionally across all disease states. All staff are trained on the importance of trust, quality time, communication and empathy when it comes to building long-term relationships with patients. Additionally, staff receive training on motivational interviewing techniques to empower patients through accepting and compassionate conversations.
  • A robust team: The typical care team at a nephrology office may include a physician, medical assistant, nurse and office manager. Strive’s care team is much more robust.  

A market-dedicated leadership team works with partners to determine needs and build a comprehensive and collaborative team of Strive Kidney Heroes™. This group forms the backbone of Strive’s Care Model. Kidney Heroes™ include nurse practitioners, registered nurse case managers, care coordinators, medical assistants, licensed clinical social workers, clinical pharmacists, registered dietitians and office managers. These highly specialized caregivers understand the complexities of kidney disease and, in conjunction with the nephrologist and medical director, work to slow or redirect disease progression. This team helps execute each patient’s clinical care plan while:

  • Facilitating a seamless, efficient and relationship-based experience for patients and their families.
  • Working proactively to identify, assess and manage care gaps that lead to complications and increased utilization.
  • Coordinating transitions of care that come naturally throughout kidney disease progression — including dialysis and transplant — and helping a patient navigate the complex ecosystem of kidney care services.
  • Predictive analytics: Strive’s care management platform integrates partner data with predictive analytics to generate meaningful insights. The technology identifies care gaps and makes predictions about disease progression so clinical teams can intervene with the right care at the right time.
  • Population health analytics tool: This web-based tool houses ongoing, real-time analytics including risk stratification, quality/outcomes reporting and program success monitoring. Strive’s risk stratification analytics enable scale by allowing Strive’s team to prioritize in-person touch points, which can make the biggest impact on patient outcomes. Strive’s analytics also help the team understand what engagement methods are most likely to be successful for different patients. Strive’s risk stratification algorithm can prioritize patients for engagement based on claims data alone and becomes even more precise as additional data types are incorporated. The population tool is also used by the interdisciplinary team to identify and proactively manage care gaps, which is a critical step to optimize outcomes and reduce costs.

The Future State with Strive

Think back to that patient in the emergency room and consider their story under the Strive Care Model. Instead of a surprise ESKD diagnosis in the acute care setting, they would have been identified at a far earlier stage in their CKD progression. They would have a nephrologist, understand their disease and prognosis and be empowered to make decisions to delay the progression of their disease for as long as possible. They would also have access to CKD education and going support so they can feel well-informed and confident in selecting the best treatment plan for their lifestyle, whether it be home-based dialysis or transplant.

Along the way, they’d have access to experts in nutrition, medication, psychosocial support and would know where to turn when faced with questions or barriers.

“A person’s journey with kidney disease is not a straight line,” Watson said. “The team at Strive recognizes that, making sure we help patients at every turn on their path toward better health. We ensure every patient is heard and understood so we can incorporate their values, preferences and voice into how we deliver whole-person care and support. That’s the kind of patient experience Strive is creating for people with kidney disease.”

To learn more about Strive’s Care Model, email or complete our contact form.

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