Bringing Modernized Kidney Care To The Home: How Monogram Health Is Transforming Polychronic Care

Nowhere has innovation been more prevalent in recent years than in healthcare – but this astounding progress has not been evenly distributed throughout all sectors of medicine, or among all Americans.

Some types of care – such as cancer care – have seen a night and day difference in clinical outcomes where once terminal diagnoses have become manageable chronic conditions or, in some cases, even entirely curable. Another is my own specialty of heart disease where risk of death from a heart attack in 2015 was half of what it was in 1960.

Other areas of clinical care, however, have been much slower to evolve, failing to modernize to the full benefit of patients and families. For proof, look no further than the care of patients with renal (or kidney) disease, where a patient on dialysis today looks almost identical to a patient on dialysis in the year 2000.

Such was the case until Monogram Health came onto the scene in 2019.

Founded and incubated by Frist Cressey Ventures (FCV) in Nashville, Tennessee, Monogram Health is on the forefront of transforming the long stagnant kidney care industry, which has historically been dominated by highly consolidated dialysis center companies. These in-facility, care-providing giants have contributed much by standardizing hemodialysis and improving patient safety, but they have fallen short on maximizing overall value and quality of life for patients. With over half a million Medicare patients on regular dialysis due to end stage renal disease (ESRD), and more than one in seven adults in the U.S. — nearly 37 million people — living with chronic kidney disease (CKD), the opportunity to improve quality of life, to better outcomes, and to lower costs with a new model of care is immense.

Four years ago, the founding Monogram team, led by clinically focused Frist Cressey Ventures and CEO Mike Uchrin, saw the need for long overdue innovation in kidney care engagement and rose to the challenge. Collectively we set out to completely reset the treatment standard for CKD, ESRD, and other polychronic conditions by prioritizing comprehensive, patient-centered care delivered at home, optimally driven by a multispecialty team in the rapidly emerging value-based environment.

Fueled by a fortuitous convergence of recent smart national policy, technological innovation in data management and medical devices, skyrocketing patient demand for care closer to home, a sea change in both patient and provider comfort levels with home-based care complemented with telemedicine, and advances in understanding risk management, Monogram Health – in a highly differentiated way – is leading the charge in modernizing kidney care. Though other outstanding, renal-based, health service companies are contributing to the much-needed transformation of kidney disease care, the Monogram approach is unique. And the following is how:

Implementing Evidence-Based, Patient-Centric Care in the Home Setting

From the outset, Monogram was founded with the patient and his or her family at the center. Patient centricity is fundamental to the Founders and to the leadership team; it pervades the culture today. This initial vision was well articulated by Monogram’s first Chief Medical Officer and nationally recognized nephrologist, Dr. Raymond Hakim: to raise the quality of care and satisfaction for all patients with CKD and ESRD. And to do so by developing and diligently applying evidence-driven protocols that lead to better patient outcomes and more cost-effective treatment, all within this costly and growing sector of health care.

Delivering care in the home, where a patient is more comfortable, feels safer, and is likely to be most compliant with appropriate treatment is essential to this vision. Through this approach, Monogram dismantles a longstanding barrier to care by enabling consistent access to patients and their families, which allows us to develop individualized care plans around patient goals, based in trusted relationships.

Three scientifically grounded and evidence-based pathways were developed (and are continually refined as new, proven knowledge unfolds):

· Polychronic disease management: to delay the progression of kidney disease by disciplined, attentive treatment of comorbidities (for example, hypertension and diabetes), with an emphasis on compliance to medication therapy and removing social determinant barriers to achieving better health outcomes;

· Patient and caregiver education: to empower patients with educational tools to make informed decisions about slowing their own disease progression and treatment options, and to make informed decisions if their disease progresses; and

· Management of end stage renal disease: to heighten attention to quality and end-of-life goals, while leveraging the “home-first” approach. Fundamentally, advanced renal disease should not be synonymous with dialysis.

The Patient Journey

Who can enroll in Monogram? Patients access Monogram through their health plan. Monogram has partnered with leading insurance providers including HumanaHUM +0.2%, Cigna, Point32Health and CenteneCNC -0.8%, as well as leading risk bearing platforms like agilon, Advent and Banner Health, all of whom seek to improve access to evidence-based care while also improving affordability of care. Monogram operates to reach all insurance products, including Medicaid populations. Its home-based care model sees no barrier related to the zip code of a patient.

Monogram works with its partners using proprietary AI-driven algorithms to identify the patients who would most benefit from this additional, personalized support.

Once a patient is enrolled in Monogram, they undergo a comprehensive clinical, medical, and social assessment, conducted in-person with an experienced nurse practitioner from the patient’s locality. The assessment includes screening for depression, inappropriate medication therapy, underlying comorbidities and access to care, as well as social determinants such as transportation and emotional support.

A carefully tailored care plan that includes personalized education is developed based on the assessment. The patient’s care is actively managed by their care providers, including Monogram’s employed group of specialists, ranging from physicians focused on nephrology, endocrinology, and cardiology to internal medicine, palliative care, and other specialties. These physicians work together to collaboratively manage the polychronic care of the patient. And behind that primary care team is a supporting team of nurse practitioners, social workers, pharmacists, nurses, and dietitians who are equipped with specific skill sets to prevent progression of polychronic disease, including chronic and end stage renal disease. They effectively manage complications, and smooth transitions if there are changes in treatment.

If the patient’s renal function deteriorates beyond certain thresholds because of progression of disease, they are assessed for eligibility for transplant, dialysis, or conservative treatment. Active education with shared decision-making is fundamental. Monogram has found that costly, emergency “dialysis crashes” into the hospital are avoidable if disease progression is identified early and an advance care plan has been made and executed.

If the patient is dialysis-eligible and elects to proceed, the Monogram team typically plans for a non-hospital dialysis start with permanent access, encouraging home alternatives to in-center dialysis. For many, peritoneal dialysis (where the inside lining of one’s abdomen acts as a natural filter with a surgically placed catheter) might be the recommended option. Patients are informed of all treatment options rather than, as in the past, automatically defaulting to in-center hemodialysis (where an external machine is used to filter waste from the blood). Other pathways, if clinically indicated, include kidney transplantation or palliative care, considered in consultation with patient, family, caregivers, and the Monogram care team.


Monogram Health was started and incubated by Frist Cressey Ventures with CEO Mike Uchrin. L to R: Chris Booker, Partner, FCV; Mike Uchrin, CEO; Senator Bill Frist, MD, Board Chair of Monogram & Founding Partner, FCV.

Changing the Status Quo in Polychronic Care

Monogram is different. The company prioritizes home-first, patient-centric engagement with a nationally scaled, value-based primary and specialty provider platform. We leverage proprietary, scientifically driven and evidence-based interventions. And, we work as far upstream as possible to prevent disease progression, ease transitions of care, and where appropriate lean on conservative kidney management without dialysis.

Healthcare innovation is all about improving the patient experience and clinical outcomes. We are increasing utilization of home dialysis, broadening access, and reducing the number of readmissions and mortality rate. Further, we are minimizing structural barriers to health and wellbeing and providing high quality, meaningful care to all patients, importantly including those who have historically been the most vulnerable and underserved.

Thanks to Monogram Health, a dialysis patient in 2023 looks a lot different than one when the company was founded in 2018. Kidney care has officially modernized, and the Monogram model has laid the groundwork to further modernize care for all chronic conditions in the years to come.

Source: Forbes