Value-Based Care at East Bay Nephrology Medical Group
Comprehensive, Physician-Led Care Beyond the Office Visit
Building on the success of our practice-wide initiatives, we have developed a range of value-based programs to enhance patient care. At East Bay Nephrology Medical Group (EBNMG), our value-based care programs are designed to provide continuous, proactive support to patients living with Chronic Kidney Disease (CKD) and complex health conditions.
By extending specialized clinical care coordination into your daily routine between office appointments, our goal is to help you maintain your quality of life, optimize treatment plans, and prevent unnecessary emergency room visits or hospitalizations.
Our Value-Based Care Programs
EBNMG participates in multiple specialized value-based care initiatives tailored to meet patients at every stage of their kidney health journey.
1. Chronic Care Management (CCM)
- Who It’s For: Patients with two or more chronic conditions (such as CKD, hypertension, diabetes, or heart disease).
- Partner Network: Offered in partnership with Vitality Kidney Care and Evergreen Connected Care.
- Key Features:
- - Dedicated Care Coordinators conducting regular text messaging and telephonic check-ins.
- - Comprehensive, personalized care plan development accessible via the patient portal.
- - Ongoing medication reconciliation and support addressing barriers to care (transportation, dietary guidance, refills).
- - Timely follow-up after hospital discharges or emergency room visits.
2. Principal Care Management (PCM)
- Who It’s For: Patients with a single high-risk or complex chronic condition (specifically Chronic Kidney Disease requiring specialized nephrology oversight).
- Partner Network: Offered exclusively through EBNMG Care Coordinators.
- Key Features:
- - Disease-specific care planning focused directly on optimizing kidney function and slowing disease progression.
- - Frequent medication adjustments and symptom tracking under the direct supervision of your EBNMG nephrologist.
- - Direct coordination between your EBNMG specialist and primary care team.
3. Integrated Kidney Care (IKC) / Comprehensive Kidney Care Contracting (CKCC)
- Who It’s For: Eligible Medicare beneficiaries with advanced CKD or Kidney Failure.
- Partner Network: Offered in partnership with Village Health / Integrated Kidney Care of Northern California.
- Key Features:
- - Specialized care manager support and wellness resources.
- - Enhanced education regarding treatment choices and health management.
- - Medicare has designed a complete kidney care program, Comprehensive Kidney Care Contracting (CKCC), that gives patients access to new services and resources in personalized care, wellness, and clinical support.
- - As a patient of East Bay Nephrology Medical Group you are part of this new program that will bring you more tools to help you better manage your health. East Bay Nephrology Medical Group, along with multiple large Nephrology practices in Northern California, have partnered with Village Health to create Integrated Kidney Care of Northern California, your personal care team, to bring you these services:
At-a-Glance Comparison
| Program | Primary Focus | Key Benefit | Enrollment |
|---|---|---|---|
| Chronic Care Management (CCM) | Multiple chronic conditions (e.g., CKD + Diabetes + Hypertension) | Continuous multi-condition care tracking & monthly check-ins | Physician referral + Patient Consent |
| Principal Care Management (PCM) | Single complex condition (e.g., High-risk CKD) | Targeted specialist care management & frequent medication oversight | Physician referral + Patient Consent |
| Integrated Kidney Care (IKC / CKCC) | Advanced CKD & ESRD Medicare beneficiaries | Comprehensive care team & wellness education resources | Medicare attribution + Consent packet |
Patient Benefits & 24/7 Clinical Support
When enrolled in our care management programs, you remain at the center of a connected care team led by your trusted EBNMG physician:
- Dedicated Care Manager: Regular outreach via secure text and phone calls to track symptoms and answer questions.
- 24/7 Access to Care: Continuous telephone access to EBNMG doctors or covering partners for urgent clinical needs.
- Patient Portal Access: View your care plan, message your care team, and track health updates anytime at portal.ebnmg.org.
Frequently Asked Questions
Q: Do these care management programs replace my regular doctor visits? A: No. CCM and PCM services complement your scheduled office appointments by providing continuous support between visits.
Q: Are these programs covered by insurance? A: Yes. Medicare and most commercial insurance plans cover CCM, PCM, and CKCC services. Standard copays or coinsurance may apply.
Q: Is participation mandatory? A: Participation is 100% voluntary. You may opt in or opt out at any time without affecting your regular nephrology care.
Get Enrolled Today
Ask your EBNMG nephrologist about enrolling in Chronic Care Management or Principal Care Management during your next appointment, or contact our central office:
- Central Office: 2905 Telegraph Ave, Berkeley, CA 94705
- Phone: (510) 841-4525
- Patient Portal: portal.ebnmg.org
If you are aligned to CKCC Program:
Keep an eye out for your IKC Welcome Packet and Notice to Patients in the mail.
Please review these materials as soon as you receive them. Watch this VIDEO to a Better Path to Kidney Care.
SIGN and RETURN your consent forms within 30 days to begin receiving new, personalized health services.
Please take a few moments to complete the PAM questionnaire, and the Health Questionnaire, helping your care team to provide you the best care possible.
Call your Village Health care team at 1-800-767-0063 Monday to Friday 7am-7pm EST (Eastern Standard Time)