Table 2.

Additional care providers in the PCMH-KD model: qualifications and duties

Team Member	Qualifications	Duties
General Internist	Board certified or eligible in internal medicine; training and/or experience with ESRD and dialysis	Primary care for comorbid conditions; preventive care, including age-appropriate cancer screening; coordinate subspecialty care
Nurse Coordinator	Masters or BSN- level nurse; training and/or experience with ESRD and dialysis	Care coordination; monitor episodic inpatient care; deliver patient education; coordinate with surgery and radiology for assessment, planning, and completion of vascular access procedures; monitor vascular access sites
Pharmacist	PharmD and RPh	Medication assessment, dosing, and safety monitoring; support medication compliance; immunizations; identify community resources for medication delivery
Community Health Workers (CHW)	Bilingual in English and Spanish (preferred); trained in medical terminology	Liaison between community, patient/family, and care team; bridge barriers of acculturation, language, and literacy; coordinate scheduling for transportation and other support to enable patient compliance