Table 4.

Kidney Transition Specialist Activities and Goals

Activities	Goals
Self-Management Empowerment • Provide and refer for education on CKD self-management • Conduct “Problem Solving Self-Care Empowerment Classes”	Enable patients’ self-care and activation
Facilitate Shared Decision-Making • Assess patients’ readiness to engage in CKD self-care and CKD decision-making and tailor intervention to patient readiness • Help patients comprehend CKD diagnosis and potential need for long-term planning about kidney failure treatments • Support shared decision-making • Ascertain values and enter in electronic health record • Review educational information on treatment modalities • Refer to kidney failure treatment modality classes • Help patient document their treatment preferences	Improve patients’ informed decision-making about kidney failure treatments
Offer Psychosocial Support • Connect to behavioral and mental health services • Connect to peer-mentors program (National Kidney Foundation) • Identify caregiver support needs and facilitate support	Connect patients to mental health and social support
Provide Care Navigation • Promote timely movement through multi-step referrals and tests (education, encouragement, assistance) • Create link between disconnected CKD clinics and dialysis or transplant centers through letters and phone calls	Navigate patients through multistep medical plans (e.g., referrals and tests)
Facilitate Team Communication • Communicate with care team to encourage alignment of care with patients’ preferences	Advocate to align patients’ care with their values