Personalized and Compassionate
In-Home Care for Polychronic Patients

Monogram Health provides evidence-based, whole-person, in-home care for patients with polychronic conditions – including chronic kidney and end-stage kidney disease – so you can focus on what matters most in life.

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The Monogram Difference

Through our unique in-home nephrology, primary care and chronic condition treatment and benefits management services, we enhance access to affordable care in all communities, drive better health outcomes and, in turn, decrease total cost of care, creating value for our patients and partners.

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Patients & Caregivers

For the more than 37 million American adults living with chronic kidney disease, access to the type of specialized care that Monogram provides is critical. We are committed to keeping you as healthy and comfortable as possible, which is why a core component of our kidney care model is visiting and caring for you right in your own home.

Our clinical practice includes nephrologists as well as cardiologists, geriatricians, endocrinologists, internal medicine specialists, nurse practitioners, registered nurses, social workers and pharmacists — all working together with you and your doctor to create a care plan that is tailored to your unique needs.

 

Health Plans

We are proud to be a next-generation specialty risk platform focusing on the diagnosis, treatment, and longitudinal care management for those with polychronic conditions, including chronic kidney and end-stage kidney disease.

Through our numerous value-based partnerships with leading health plans as well as risk-bearing platforms, we care for patients across 35 states and all insurance products, improving access to evidence-based care while also improving the affordability of care through reduced medical expenses.

Our clinical outcomes show the Monogram difference: we have doubled planned dialysis transitions, tripled rates of home dialysis, and halved readmission rates from the national average for our current plan partners.

 
 

28%

Home Dialysis Utilization Rate

Tripling Rate of Home Dialysis
(10% national avg.)

 

70%

New Patient Engagement

70% engagement rate of referred / identified Health Plan members

45%

Planned Dialysis Starts

More than doubling rate of planned starts
(20% national avg.)

 

25%

Evidence-Based Criteria

Over a quarter of transition patients promoted to conservative care to improve outcome.

18%

Reduction in Readmission Rates

Halving re-admission rate
(35% national avg.)

 

$1000 PMPM

Risk Contribution

Average across all health plan clients

 

All statistics as reported from USRDS data

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Providers

We support clinicians by working with your patients to more effectively develop and implement their plan of care.

Our team of nurse care managers, dieticians, pharmacists and social workers help patients understand their condition, improve medication adherence, identify community and support resources, and coordinate care services… at no extra cost to your clinic.

 
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Our Story

Our name, Monogram, symbolizes the personalized focus of our services.

While the application of the latest technology and data science is critical to our success, we never lose sight that health care is ultimately about trusted individual relationships between health care professionals and their patients.

Unfortunately, individuals living with polychronic conditions, including advanced chronic kidney disease and end-stage kidney disease, often face dismal health outcomes and poor quality of life due to barriers in accessing care and a deeply entrenched, volume-first system with poor adherence to evidence-based care and a lack of sensitivity to social determinants of health.

The 21st Century Cures Act is a seminal piece of legislation designed to shift individuals living with ESKD from fee-for-service Medicare into managed care programs and reverse decades and decades of sub-optimal outcomes. Monogram was born with a vision to serve health plans and other health care sponsors to solve these systemic problems. Our mission is to transform the way health care is delivered for those with kidney disease so they can lead healthier, happier, and more fulfilling lives. Our innovative, in-home kidney care model is proven to enhance clinical outcomes by predicting the onset of CKD and ESKD, slowing disease progression, and reducing hospitalizations, morbidity and mortality.

We are founded and operated by a core group of former government programs health plan executives, including our CEO, Michael Uchrin; a world-renowned nephrologist and author of over 200 published pieces of research, Dr. Raymond Hakim; and former U.S. Senator Bill Frist M.D., a retired cardiac surgeon and recognized leader for improving the quality of care provided to people across the world.

We welcome all stakeholders in the CKD | ESKD ecosystem to join us in achieving our vision of maximizing the health of all people with kidney disease.

 

Select Partners

Trusted by the nation’s leading health plans.

The Monogram Health Footprint