Based on this assessment, and in conjunction with the patient, patient's nephrologist & PCP, and other members of the care team, create and implement a care plan that will address identified needs, remove barriers to care, and improve the health of the patient; Coordinate care by serving as the advocate and resource for the patient, their family, and their provider(s); Facilitate care across the continuum of care, spanning settings such as the home, hospital, skilled nursing facility, and acute care facility; Manage patients during periods of transitions of care to facilitate effective transitions and minimize avoidable readmissions; Assess the patient's knowledge of their renal condition and provide education and self-management support; Provide ongoing reassessment and follow-up to improve patient outcomes. The primary focus will be to improve patient outcomes by helping patients get permanent access, promoting home dialysis modalities & kidney transplantation, educating patients on self-management, addressing risks associated with comorbid conditions, and coordinating their care.