Table 2.

Interventions made by nurse case manager

CategoryInterventionNumber of patients
Coordination of careLaboratory workup appointment coordination19
Appointment reminders18
Medication reconciliation17
Streamline appointment schedule15
Transition to CKD clinic7
Arrange weighing scale4
Obtain BP cuff2
Communication with cliniciansPrimary care physician11
Nephrologist9
Surgeon/wound care7
Nursing/rehabilitation facility6
Cardiologist4
Other medical specialty4
Urology2
Neurosurgery1
Pharmacist1
Self-management educationMedication adherence/side effects15
Volume management12
Diet6
Postdischarge AKI education4
Hypoglycemia management3
Nausea/fatigue management3
Disease-specific plan of careInfection5
Depression4
Diabetes4
Dialysis4
Congestive heart failure4
Wound care3
Symptom detectionDepression/anxiety6
Edema5
Weight gain4
Dysuria1
Chest pain1
Socioeconomic supportCaregiver support10
Safety/mobility support9
Transportation5
Substance abuse3
Financial hardship2
Personal/family conflict2
Need-based referralsBehavioral health3
Home health2
Physical/speech therapy2
Cardiology1
Dietitian1
Home oxygen therapy1
  • Each intervention counted only once per patient, but the same patient could be included under multiple interventions.