March is National Kidney Month—a time to raise awareness about the importance of early detection and proactive management of chronic kidney disease (CKD), which affects more than one in seven U.S. adults. At Navina, we’re proud to support organizations that are pushing kidney care forward through innovative, value-based approaches, like our partners at Evergreen Nephrology.
In that spirit, Dr. Ronen Gordon, VP of Medical Product at Navina, sat down with Kimberly Suarez, CPC, CRC, CPC-I, CIRCC, CDEO, CPCO, VP of Documentation, Coding, and Quality Improvement at Evergreen Nephrology. They discussed how Evergreen is providing better kidney care through coordinated care models, smart technology, and AI-powered insights.
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What makes Evergreen Nephrology unique?
Dr. Ronen Gordon: Kim, thanks for joining us. To start, tell me a bit about Evergreen Nephrology and what makes you unique.
Kimberly Suarez: At Evergreen Nephrology, we're committed to partnering with nephrologists and payers to provide the best possible care for people living with chronic and end-stage kidney disease. Our focus is on slowing disease progression for these patients, improving their outcomes, and making real differences in their lives. Here at Evergreen we know that nephrologists want to spend more time with their patients, not on administrative tasks, and that's why we bring in dedicated care teams and smart technology to help lighten the load, making it easier to deliver personalized, high quality care. And with AI-driven insights and better access to EHR data, we're able to simplify information sharing and improve care coordination. Our goal is to make sure nephrologists always have the support and resources that they need so that they can focus on what they do best, which is taking care of their patients.
Why is kidney health a critical issue?
Dr. Ronen Gordon: We've been working together for a while now, and you guys are a great team. We see your dedication to delivering top-class kidney care. Why is kidney health such a critical issue right now?
Kimberly Suarez: Chronic kidney disease affects over one in seven US adults, yet up to 90% of them don't even know that they have it. Since there's no cure outside of a transplant, early detection and management are crucial to slowing the progression of kidney disease. Preventing further damage entails addressing underlying conditions like diabetes and hypertension, which are on the rise. CKD also places a significant burden on older adults, driving up healthcare costs. So prioritizing prevention and better management can help people live healthier, longer lives.
Why is specialy care moving into value-based care models
Dr. Ronen Gordon: So what I'm hearing from you is just a massively underdiagnosed population, with so many Americans living with this—a lot of people don't necessarily know that. As CKD becomes a bigger issue, we’re seeing more specialty care—especially nephrology—move into value-based care models. Why do you think that shift is happening?
Kimberly Suarez: I think nephrology is shifting to value-based care because kidney disease is complex and patients need more than just routine visits. They need proactive coordinated care that helps them stay healthier longer. So while value-based care started in primary care, its success has led CMS and payers to expand the model to specialists to manage these chronic conditions. For CKD patients, nephrologists often become the main provider as the disease progresses. That makes them central to delivering the kind of coordinated, outcomes-focused care that value-based models are built on.
Evergreen's approach of the transition to value-based care
Dr. Ronen Gordon: And how has Evergreen approached that transition?
Kimberly Suarez: Evergreen empowers nephrologists with the right tools and support to improve patient outcomes while lowering costs through proactive coordinated care. At Evergreen we support nephrologists with a care management platform that integrates within their EMR, making it easier for them to manage value-based care, right at the point of care. And through our partnership with Navina, we simplify data insights, coding, accuracy, reducing administrative work so that the nephrologist can focus on their patients. So beyond all of the technology, our dedicated care teams and clinical programs help nephrologists navigate complex patient needs, ensuring better engagement and support every step of the way.
How Evergreen ensures comprehensive patient management
Dr. Ronen Gordon: How do you ensure comprehensive patient management when you have your patients seeing other providers?
Kimberly Suarez: That’s one of the things that makes Evergreen unique. Our nephrologists are at the center of patient care, and we're here to make sure that they have the support that they need both in and out of the office. Our dedicated care teams—nurse care managers, care coordinators, social workers, dieticians, and pharmacists—work hand in hand with nephrology practices to extend their reach and provide that ongoing patient support. So whether it's managing care transitions, chronic conditions, behavioral health or urgent needs, Evergreen is here to help ensure that patients get the right care at the right time in supporting our nephrologists. They're really becoming that central coordination point for all of those patients as well.
How is Evergreen using technology?
Dr. Ronen Gordon: What challenges come with playing that central role? And how are you using technology—and AI in particular—to meet those challenges?
Kimberly Suarez: So we partner with Navina to bring in AI-powered insights. Those insights help nephrologists make more informed decisions, and ensure patients receive the right care at the right time. For patients who live in rural areas, patients who don't have all of the resources available to them, having AI helps us make that outreach to these patients. We have a CDI team that supports our nephrologists to enhance documentation integrity, making sure medical records fully reflect the patient's conditions. The AI-driven support helps us minimize errors and omissions, leading to better care coordination and more precise treatment planning. One of the important things to call out, and Navina has helped strengthen our approach, has been in transforming clinical data. Eliminating time-consuming searches and improving coding accuracy and efficiency for our CDI team. But it also helps us capture and optimize those risk adjustment quality measures, other key quality benchmarks. But lastly, I think combined with the power of Navina's AI and our dedicated Evergreen CDI team, we're making it a lot easier for nephrologists to provide the highest quality of care while ensuring accurate and complete documentation for these patients. That has been a big challenge, across all markets. Documentation integrity, documenting accurately and appropriately has always been a challenge. Having AI helps us in that aspect.
What are the biggest areas for innovation in kidney care?
Dr. Ronen Gordon: Looking ahead, where do you see the biggest opportunities for innovation in kidney care?
Kimberly Suarez: When I think about opportunities for innovation, the first thing that comes to my mind is reducing administrative burden. With fewer nephrologists entering the field, AI is stepping in to handle time-consuming tasks, like scheduling, data management, and it's giving the providers more time to focus on patient care. I also think about improving access to care. Many patients, as I mentioned earlier, are in rural areas. They struggle to find quality healthcare. AI-powered EHR integration helps ensure timely health data, making communication and care coordination smoother for those patients. And when I think about innovation, I think about breakthrough medications, like the GLP-1 receptor agonists, the SGLT-2 inhibitors that are slowing the CKD progression by managing chronic conditions, like diabetes and hypertension. Meanwhile, AI is transforming research and care coordination, helping providers detect risks earlier on to take action before kidney disease worsens. And I think that is the most important call-out in how I see this opportunity for innovation in the future.
Dr. Ronen Gordon: And since it’s Kidney Month—are there any special initiatives happening at Evergreen right now?
Kimberly Suarez: I like to say that every month is Kidney Month at Evergreen. Our patients are really complex, and our goal is to ensure that we can help nephrologists provide the care for these patients, because they really do require that special, dedicated care.
Dr. Ronen Gordon: Kim, thank you so much for joining me and sharing your insights. We're really proud of our partnership with Evergreen Nephrology and being able to help you in your efforts in improving patient care. Thank you.
Kimberly Suarez: Thank you so much for having me.
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