--- title: Kidney Care is Fragmented. Value-Based Models Can’t Wait description: Discover how nephrology practices can meet value-based care goals with tech-enabled solutions that simplify care delivery—without overloading providers. image: https://www.accuhealth.tech/hubfs/AdobeStock_846879835.jpeg --- # Kidney Care is Fragmented. Value-Based Models Can’t Wait ![David Medeiros](https://www.accuhealth.tech/hs-fs/hubfs/David_M._B.g__2_-removebg-preview.png?noresize&width=80&height=80&name=David_M._B.g__2_-removebg-preview.png) Published by: [David Medeiros](https://www.accuhealth.tech/blog/author/david-medeiros) on Published On: 07/02/2025 • Updated: 07/30/2025 • 6 minute read --- Share this Post: - [Share on Twitter ](https://twitter.com/intent/tweet?original_referer=https://www.accuhealth.tech/blog/kidney-care-is-fragmented.-value-based-models-cant-wait&utm_medium=social&utm_source=Twitter&url=https://www.accuhealth.tech/blog/kidney-care-is-fragmented.-value-based-models-cant-wait&utm_medium=social&utm_source=Twitter&source=tweetbutton&text=) - [Share on Facebook ](http://www.facebook.com/share.php?u=https://www.accuhealth.tech/blog/kidney-care-is-fragmented.-value-based-models-cant-wait&utm_medium=social&utm_source=Facebook) - [Share on LinkedIn ](http://www.linkedin.com/shareArticle?mini=true&url=https://www.accuhealth.tech/blog/kidney-care-is-fragmented.-value-based-models-cant-wait&utm_medium=social&utm_source=LinkedIn) - [Share on Pinterest ](http://pinterest.com/pin/create/button/?url=https://www.accuhealth.tech/blog/kidney-care-is-fragmented.-value-based-models-cant-wait&utm_medium=social&utm_source=Pinterest&media=https://7986850.fs1.hubspotusercontent-na1.net/hubfs/7986850/AdobeStock_846879835.jpeg) - [Share on Email ](mailto:?subject=Check%20out%20https://www.accuhealth.tech/blog/kidney-care-is-fragmented.-value-based-models-cant-wait&utm_medium=social&utm_source=Email&body=Check%20out%20https://www.accuhealth.tech/blog/kidney-care-is-fragmented.-value-based-models-cant-wait&utm_medium=social&utm_source=Email) --- Chronic kidney disease (CKD) is one of the most costly, complex, and rapidly growing public health challenges in the United States. More than 37 million Americans are affected—and many don’t even know it. For nephrology practices, this creates an urgent need to deliver proactive, coordinated care in a system that wasn’t designed to support it. That urgency has reached a breaking point. Traditional care models built around episodic, in-office visits are failing to meet the needs of patients with progressive kidney disease. Meanwhile, value-based care models like KCC (Kidney Care Choices) are redefining what success looks like—focusing on prevention, coordination, and outcomes. So why is delivering that kind of care still so difficult? ## Why Kidney Care is Still So Fragmented The [nephrology care journey is long and non-linear](https://www.accuhealth.tech/blog/how-nephrology-ccm-platforms-enhance-chronic-kidney-disease-ckd-management). Most patients live with CKD for years before progressing to end-stage renal disease (ESRD), often with little visibility into their health status between appointments. Nephrologists are expected to: - Track complex, dynamic lab trends - Coordinate with primary care and specialists - Monitor for hospitalizations or acute declines - Manage comorbidities like diabetes or hypertension - Educate patients on lifestyle, diet, and dialysis planning And yet, most of this work happens without real-time data or between disconnected systems.  Plainly speaking, why is the current care system failing CKD patients? - Siloed systems - patients have to navigate individual care systems and practices on top of managing a notoriously high-maintenance disease - Episodic care - care becomes about managing escalations and issues rather than sustained improvement - Missed opportunities for early intervention - downside risk gets the most attention and care, while preventable escalation is overlooked - Over-reliance on in-office visits - healthcare teams are constantly asked to do more with less and the patients pay the price So, where do we go from here? ## The Shift to Value-Based Kidney Care In response to these [challenges](https://www.accuhealth.tech/blog/transforming-chronic-kidney-disease-ckd-care-the-role-of-remote-monitoring-chronic-care-management), CMS introduced the KCC model to encourage longitudinal, team-based care for CKD and ESRD patients. Shared savings incentives are tied to reducing hospitalizations, delaying dialysis starts, and improving quality of life. But the care infrastructure needed to support that model doesn’t exist in most practices. That’s where remote care services like Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) come in. ![AdobeStock_846879835](https://www.accuhealth.tech/hs-fs/hubfs/AdobeStock_846879835.jpeg?width=4032&height=2688&name=AdobeStock_846879835.jpeg) ## Remote Care Isn’t Just for Primary Care While CCM and RPM are commonly used in primary care, their application in nephrology is increasingly critical. Patients with CKD and ESRD are ideal candidates for proactive, in-between-visit care. [Remote care tools help nephrologists](https://www.accuhealth.tech/blog/how-nephrology-ccm-platforms-enhance-chronic-kidney-disease-ckd-management): - Identify early warning signs (e.g., blood pressure spikes, weight gain) - Maintain patient engagement between visits - Coordinate care across multiple specialists - Improve adherence to treatment plans - Reduce emergency visits and readmissions These aren’t just clinical wins—they’re financial ones. Most CCM and [RPM services](https://tellihealth.com/resources/how-is-rpm-implemented-into-your-organization) are Medicare-reimbursable and contribute directly to quality performance metrics. [Learn more about how remote care helps your patients.](https://tellihealth.com/resources/the-impact-of-rpm-on-patient-outcomes) ## Tellihealth: Enabling Nephrologists to Scale Their Impact At Tellihealth, we recognize that nephrologists don’t need more systems to log into—they need solutions that integrate with their workflows and support their patients behind the scenes. Our platform enables practices to: - Deliver monthly, nurse-led CCM touchpoints (via signalCCM) - Track real-time vitals with connected RPM devices (via accuRPM) - Support shared decision-making with actionable insights - Operate within CMS frameworks like KCC with confidence And most importantly, we do it without burdening your staff or disrupting the provider-patient relationship. ## It’s Time to Rethink Kidney Care CKD and ESRD patients deserve more than episodic attention—they need coordinated, continuous support. And nephrology practices deserve tools that help them deliver that care without burning out. The question isn’t *if* remote care belongs in nephrology. It’s *how fast* we can scale it to the patients who need it most. ### Want to see how connected care fits into your nephrology practice? Our next post will break down exactly how Tellihealth's nephrology care model works—with a look inside our data insights, clinical workflows, and patient impact stories. ![AdobeStock_1019635063](https://www.accuhealth.tech/hs-fs/hubfs/AdobeStock_1019635063.jpeg?width=800&height=533&name=AdobeStock_1019635063.jpeg) ## Frequently Asked Questions About CCM, RPM, and Nephrology Care ### ▸ How does Tellihealth support patients with kidney disease? Tellihealth offers proactive care for nephrology patients through real-time RPM devices, nurse-led CCM support, and personalized care plans—all designed to prevent complications and reduce hospitalizations. #### ▸ What makes Tellihealth different from other remote care providers? Unlike most vendors, Tellihealth unifies clinical teams, devices, and data into one platform. This means fewer handoffs, faster interventions, and a smoother experience for patients and providers alike. #### ▸ Is Tellihealth’s care model covered by Medicare? Yes. Our services are aligned with CMS billing codes for CCM (e.g., 99490) and RPM (e.g., 99457), making it easy for practices to receive reimbursements for remote care delivery. #### ▸ Can nephrologists use Tellihealth’s platform for specialty care? Absolutely. Tellihealth’s nephrology-focused program helps practices manage patients with ESRD, diabetes, hypertension, and other comorbidities through customized remote care pathways. #### ▸ How quickly can a nephrology clinic get started with Tellihealth? Most practices can launch within 30–60 days. Our onboarding team handles implementation, training, and EHR integration—so your staff can stay focused on care. #### Ready to deliver smarter, patient-first nephrology care? Tellihealth’s integrated CCM and RPM solutions are built to simplify operations, empower clinicians, and improve outcomes—starting with your highest-risk patients. [**Book a demo**](https://meetings.hubspot.com/dmedeiros1/tellihealth-schedule-demo?uuid=2d11d56c-f330-4da4-a63f-a632e5268bdd) to see how we can support your nephrology practice --- Filed under: - [Chronic Care Management](https://www.accuhealth.tech/blog/tag/chronic-care-management), - [RPM Info](https://www.accuhealth.tech/blog/tag/rpm-info) --- ## Related Posts Start swiping below to see related posts. ## Meet the Author Accuhealth is proud to feature content from industry-leading experts that contribute in-depth knowledge of Remote Patient Monitoring and Telehealth subject matter to our blog. ![David Medeiros](https://www.accuhealth.tech/hs-fs/hubfs/David_M._B.g__2_-removebg-preview.png?width=300&height=300&name=David_M._B.g__2_-removebg-preview.png) ### [David Medeiros](https://www.accuhealth.tech/blog/author/david-medeiros) David Medeiros is a Remote Patient Monitoring expert with 10 years of clinical, telehealth and home care experience, specifically in Remote Patient Monitoring. With his team, David has been able to develop RPM/Telehealth from the early pilot years, to the industry leading juggernaut that Accuhealth is today. Follow David Medeiros on - [Visit David Medeiros's LinkedIn ](https://www.linkedin.com/in/david-medeiros-885860242/) - [Visit David Medeiros's Website ](https://accuhealth.tech) Ready to Setup Your Clinic? Just click the link below to talk to a member of our sales team or to learn more about our Remote Patient Monitoring solution and get your clinic setup in under 24 hours. [![Schedule a Demo](https://no-cache.hubspot.com/cta/default/7986850/7833cb86-9c3b-49fc-a567-88ea02117770.png) ](https://cta-redirect.hubspot.com/cta/redirect/7986850/7833cb86-9c3b-49fc-a567-88ea02117770) × Stay connected! Signup for the latest news in Telehealth and Remote Patient Monitoring. ```json { "@context": [ "https://schema.org", { "@language": "en-US" } ], "@graph": [ { "@context": "http://schema.org", "@type": "WebSite", "@id": "https://www.accuhealth.tech/#/website", "url": "https://www.accuhealth.tech", "name": "Accuhealth Technologies LLC", "potentialAction":[ { "@type":"SearchAction", "target":"https://www.accuhealth.tech/hs-search-results?term={search_term_string}", "query-input": { "@type": "PropertyValueSpecification", "valueName": "search_term_string", "valueRequired": true } } ], "inLanguage": "en-US", "publisher": { "@id": "https://www.accuhealth.tech/#/organization" } }, { "@type":"WebPage", "@id":"https://www.accuhealth.tech/blog/kidney-care-is-fragmented.-value-based-models-cant-wait/#/webpage", "url":"https://www.accuhealth.tech/blog/kidney-care-is-fragmented.-value-based-models-cant-wait", "name":"Kidney Care is Fragmented. 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", "timeRequired": "PT6M" , "image": { "@type": "ImageObject", "@id": "https://7986850.fs1.hubspotusercontent-na1.net/hubfs/7986850/AdobeStock_846879835.jpeg", "url": "https://7986850.fs1.hubspotusercontent-na1.net/hubfs/7986850/AdobeStock_846879835.jpeg", "contentUrl": "https://7986850.fs1.hubspotusercontent-na1.net/hubfs/7986850/AdobeStock_846879835.jpeg", "representativeOfPage": "https://schema.org/True" ,"width": 4032 ,"height": 2688 } ,"sharedContent": [ {"@id":"https://7986850.fs1.hubspotusercontent-na1.net/hubfs/7986850/AdobeStock_846879835.jpeg","@type":"ImageObject","contentUrl":"https://7986850.fs1.hubspotusercontent-na1.net/hubfs/7986850/AdobeStock_846879835.jpeg","height":"2688","representativeOfPage":"https://schema.org/False","url":"https://7986850.fs1.hubspotusercontent-na1.net/hubfs/7986850/AdobeStock_846879835.jpeg","width":"4032"}, {"@id":"https://7986850.fs1.hubspotusercontent-na1.net/hubfs/7986850/AdobeStock_1019635063.jpeg","@type":"ImageObject","contentUrl":"https://7986850.fs1.hubspotusercontent-na1.net/hubfs/7986850/AdobeStock_1019635063.jpeg","height":"533","representativeOfPage":"https://schema.org/False","url":"https://7986850.fs1.hubspotusercontent-na1.net/hubfs/7986850/AdobeStock_1019635063.jpeg","width":"800"} ] ,"author": { "@type": "Person", "@id": "https://www.accuhealth.tech/#/person/44630448247", "url": "https://www.accuhealth.tech/blog/author/david-medeiros", "name": "David Medeiros" }, "creator": { "@type": "Organization", "name": "Accuhealth Technologies LLC", "logo": { "@type": "ImageObject", "@id": "https://www.accuhealth.tech/#/organization/logo/1" }, "@id": "https://www.accuhealth.tech/#/organization" }, "sourceOrganization": { "@type": "Organization", "name": "Accuhealth Technologies LLC", "logo": { "@type": "ImageObject", "@id": "https://www.accuhealth.tech/#/organization/logo/1" }, "@id": "https://www.accuhealth.tech/#/organization" }, "publisher": { "@type": "Organization", "name": "Accuhealth Technologies LLC", "logo": { "@type": "ImageObject", "@id": "https://www.accuhealth.tech/#/organization/logo/1" }, "@id": "https://www.accuhealth.tech/#/organization" }, "copyrightHolder": { "@type": "Organization", "name": "Accuhealth Technologies LLC", "logo": { "@type": "ImageObject", "@id": "https://www.accuhealth.tech/#/organization/logo/1" }, "@id": "https://www.accuhealth.tech/#/organization" }, "copyrightNotice": "Copyright © 2025 Accuhealth Technologies LLC", "copyrightYear": "2025", "isPartOf": { "@id": "https://www.accuhealth.tech/blog/kidney-care-is-fragmented.-value-based-models-cant-wait/#/webpage" }, "mainEntityOfPage": { "@id": "https://www.accuhealth.tech/blog/kidney-care-is-fragmented.-value-based-models-cant-wait/#/webpage" }, "commentCount": 0, "wordCount": 1545, "articleBody": "Chronic kidney disease (CKD) is one of the most costly, complex, and rapidly growing public health challenges in the United States. More than 37 million Americans are affected\u2014and many don\u2019t even know it. For nephrology practices, this creates an urgent need to deliver proactive, coordinated care in a system that wasn\u2019t designed to support it. That urgency has reached a breaking point. Traditional care models built around episodic, in-office visits are failing to meet the needs of patients with progressive kidney disease. Meanwhile, value-based care models like KCC (Kidney Care Choices) are redefining what success looks like\u2014focusing on prevention, coordination, and outcomes. So why is delivering that kind of care still so difficult? Why Kidney Care is Still So Fragmented The nephrology care journey is long and non-linear. Most patients live with CKD for years before progressing to end-stage renal disease (ESRD), often with little visibility into their health status between appointments. Nephrologists are expected to: Track complex, dynamic lab trends Coordinate with primary care and specialists Monitor for hospitalizations or acute declines Manage comorbidities like diabetes or hypertension Educate patients on lifestyle, diet, and dialysis planning And yet, most of this work happens without real-time data or between disconnected systems. Plainly speaking, why is the current care system failing CKD patients? Siloed systems - patients have to navigate individual care systems and practices on top of managing a notoriously high-maintenance disease Episodic care - care becomes about managing escalations and issues rather than sustained improvement Missed opportunities for early intervention - downside risk gets the most attention and care, while preventable escalation is overlooked Over-reliance on in-office visits - healthcare teams are constantly asked to do more with less and the patients pay the price So, where do we go from here? The Shift to Value-Based Kidney Care In response to these challenges, CMS introduced the KCC model to encourage longitudinal, team-based care for CKD and ESRD patients. Shared savings incentives are tied to reducing hospitalizations, delaying dialysis starts, and improving quality of life. But the care infrastructure needed to support that model doesn\u2019t exist in most practices. That\u2019s where remote care services like Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) come in. Remote Care Isn\u2019t Just for Primary Care While CCM and RPM are commonly used in primary care, their application in nephrology is increasingly critical. Patients with CKD and ESRD are ideal candidates for proactive, in-between-visit care. Remote care tools help nephrologists: Identify early warning signs (e.g., blood pressure spikes, weight gain) Maintain patient engagement between visits Coordinate care across multiple specialists Improve adherence to treatment plans Reduce emergency visits and readmissions These aren\u2019t just clinical wins\u2014they\u2019re financial ones. Most CCM and RPM services are Medicare-reimbursable and contribute directly to quality performance metrics. Learn more about how remote care helps your patients. Tellihealth: Enabling Nephrologists to Scale Their Impact At Tellihealth, we recognize that nephrologists don\u2019t need more systems to log into\u2014they need solutions that integrate with their workflows and support their patients behind the scenes. Our platform enables practices to: Deliver monthly, nurse-led CCM touchpoints (via signalCCM) Track real-time vitals with connected RPM devices (via accuRPM) Support shared decision-making with actionable insights Operate within CMS frameworks like KCC with confidence And most importantly, we do it without burdening your staff or disrupting the provider-patient relationship. It\u2019s Time to Rethink Kidney Care CKD and ESRD patients deserve more than episodic attention\u2014they need coordinated, continuous support. And nephrology practices deserve tools that help them deliver that care without burning out. The question isn\u2019t if remote care belongs in nephrology. It\u2019s how fast we can scale it to the patients who need it most. Want to see how connected care fits into your nephrology practice? Our next post will break down exactly how Tellihealth's nephrology care model works\u2014with a look inside our data insights, clinical workflows, and patient impact stories. Frequently Asked Questions About CCM, RPM, and Nephrology Care \u25B8 How does Tellihealth support patients with kidney disease? Tellihealth offers proactive care for nephrology patients through real-time RPM devices, nurse-led CCM support, and personalized care plans\u2014all designed to prevent complications and reduce hospitalizations. \u25B8 What makes Tellihealth different from other remote care providers? Unlike most vendors, Tellihealth unifies clinical teams, devices, and data into one platform. This means fewer handoffs, faster interventions, and a smoother experience for patients and providers alike. \u25B8 Is Tellihealth\u2019s care model covered by Medicare? Yes. Our services are aligned with CMS billing codes for CCM (e.g., 99490) and RPM (e.g., 99457), making it easy for practices to receive reimbursements for remote care delivery. \u25B8 Can nephrologists use Tellihealth\u2019s platform for specialty care? Absolutely. Tellihealth\u2019s nephrology-focused program helps practices manage patients with ESRD, diabetes, hypertension, and other comorbidities through customized remote care pathways. \u25B8 How quickly can a nephrology clinic get started with Tellihealth? Most practices can launch within 30\u201360 days. Our onboarding team handles implementation, training, and EHR integration\u2014so your staff can stay focused on care. Ready to deliver smarter, patient-first nephrology care? Tellihealth\u2019s integrated CCM and RPM solutions are built to simplify operations, empower clinicians, and improve outcomes\u2014starting with your highest-risk patients. Book a demo to see how we can support your nephrology practice", "speakable": { "@type": "SpeakableSpecification", "cssSelector": [ ".title", ".summary", "#hs_cos_wrapper_post_body" ] } , "articleSection": [ "RPM Info", "Chronic Care Management" ] } ] } ```