Why CKD Patients Fall Through the Cracks and How Healthmap Solutions’ Navigators Bridge the Gap

In the U.S., millions of adults have CKD, yet identification, follow-up, and day-to-day self-management remain uneven across communities and health plans. In this episode of the The Strategy of Health podcast, we spoke with Howard Shaps, MD, MBA , Chief Medical Officer at Healthmap Solutions, about why patients slip through the system and how Healthmap’s care navigators help close the gap.

Dr. Shaps’ perspective spans the emergency department, plan leadership at national insurers, and population health operations. His central point is disarmingly pragmatic: “We need to have patients see their doctors, take the right medications, stay on their medications—and if you do that, as well as diet and lifestyle, you go a long way.”

Why do CKD patients fall through the cracks?

They fall through the cracks because complexity meets limited bandwidth. CKD coexists with diabetes, hypertension, and cardiovascular disease, and the clinical plan is only as strong as what happens after the visit. As Dr. Shaps explained, “The docs are really good… what they don’t have are eyes and ears outside their four walls.” Patients may mishear instructions, lack transportation, skip refills, or face food insecurity and behavioral challenges that derail adherence.

Key reasons patients slip

Late recognition: Many patients aren’t identified until Stage 3–5, when risk escalates.

Fragmented accountability: PCPs, nephrologists, cardiologists, and pharmacies operate in parallel, not as a coordinated system.

SDOH headwinds: Transportation, literacy, and affordability issues hinder execution of even the best care plans.

Short clinical touchpoints: Fifteen minutes can’t compete with daily habits; as Shaps put it, “It’s hard to change behavior overnight.”

What makes CKD management uniquely hard for community physicians and health plans?

It’s uniquely hard because CKD isn’t a single disease—it’s a risk multiplier woven through multiple specialties and settings. Community physicians can write the right prescription; the challenge is what happens next. Plans can see claims, but not always the nuance of readiness, knowledge, or barriers at the member level.

From Dr. Shaps: “Patients may forget to fill prescriptions or they don’t have transportation… I can’t tell you how many times we’ve talked to patients who said, ‘I didn’t understand anything that was told to me.’” For health plans, the difficulty is prioritization and timing: Who is most likely to decompensate in the next 12 months, and what intervention—clinical, social, behavioral—will matter most right now?

The practical pain points

1. Polypharmacy and contraindications across cardiometabolic conditions.
2. Variable nephrology access amid perceived specialist shortages.
3. Data latency—claims arrive after the fact; clinical data is siloed.
4. Benefit design complexity—members struggle to navigate referrals, surgeries (e.g., dialysis access), and cost-sharing.

How does Healthmaps’ navigator model actually work?

Healthmaps’ navigator model identifies high-risk members early, activates support outside clinic walls, and closes loops with providers. In Dr. Shaps’ words, “We’ve looked at millions and millions of lines of claims data, clinical data, and other data points… our risk-stratification engine shows who is higher or medium risk for an acute event in the next 12 months.” Technology spots the signal; people move the needle.

A simple, repeatable flow:

1. Detect: AI-driven risk stratification flags members by event risk and care opportunities (labs due, missed refills, ED use).
2. Engage: Nurse navigators call, text, and educate—clarifying meds, scheduling visits, solving transport issues.
3. Coordinate: Navigators share timely insights with PCPs, nephrologists, cardiologists, and endocrinologists.
4. Escalate: For Stage 4–5, navigators initiate transplant-first conversations and early dialysis education.
5. Reassess: Knowledge checks and outcome tracking refine the plan.

The “secret sauce” is an operating system that blends analytics and human connection. As Shaps put it, “The secret sauce is technology—but there’s a people component as well, and a clinical operations component.”

Why partner with Healthmap Solutions instead of building in-house?

Because time, talent, and tight execution matter more than theory. Plans can build, but accruing the data science, protocols, clinical operations, and feedback loops that work at scale takes years. “Can payers do it or can other companies do it? Yes—we think we do it really well,” Shaps noted, pointing to a decade of iteration.

Build vs. Partner—what usually decides it:

Speed to value: Ready-made models and workflows compress the learning curve.

Operational depth: Hiring, training, and supervising navigators at scale is nontrivial.

Provider trust: A vendor that acts as an extension of the clinic earns access and attention.

Governance and economics: Risk arrangements reward those with proven reduction in avoidable utilization.

Which outcomes matter most—and how do navigators move them?

The outcomes that matter most are preventable ED visits, unnecessary admissions, avoidable readmissions, and slowed CKD progression. Healthmap orients interventions squarely around these. “We reduce unnecessary hospitalizations, reduce emergency department visits, reduce readmissions… we slow CKD progression,” Shaps said. Why these? Because they reflect both quality and cost, show up in Medicare Stars, and align incentives across member, provider, and plan.

Navigator levers tied to outcomes:

Medication optimization: Reconcile meds; escalate cardiometabolic therapy opportunities.

Timely specialty care: Ensure nephrology and cardiovascular follow-up happens on time.

Lab vigilance: Close gaps in eGFR, UACR, and other required tests for risk staging.

Barrier removal: Ride coordination, refill reminders, caregiver education.

Behavioral activation: Brief motivational coaching that sticks after the call.

When navigators act as “eyes and ears,” physicians can practice at the top of their license—and members arrive prepared.

Why is early identification (Stage 3) the tipping point?

Because Stage 3 is where trajectory becomes malleable at scale. Shaps emphasized, “We try to identify patients that have Stage 3 CKD… identifying them early is really important because sometimes it’s not identified.” Many Stage 3 patients can be managed expertly in primary care with selective nephrology referral, but someone must orchestrate labs, meds, and comorbidities consistently.

He added a stark reminder: “There’s a lot of kidney disease out there—15% of all U.S. adults, about 37 million people.” For leaders, that prevalence means a broad early-stage strategy beats a narrow late-stage rescue. Early detection paired with navigation also nudges upstream screening—catching Stage 1–2 among patients with diabetes or hypertension.

Your early-stage checklist:

1. Standardize CKD risk flagging inside primary care registries.
2. Embed navigator outreach on missed labs and med lapses.
3. Stand up rapid nephrology tele-consults for “gray zone” cases.
4. Track conversion from identification → first nephrology visit.

What happens when acuity rises—how do navigators bridge the hardest moments?

They prepare, guide, and prevent “crashes.” For Stage 4–5, Healthmap’s navigators begin with readiness assessments, then move quickly to key decisions. “We’ll start the conversations early about transplant—and transplant first, because that’s always the best alternative,” Shaps said. In parallel, they demystify dialysis—options, home modalities, and lifestyle impacts—and ensure vascular access is planned before a crisis hits.

High-acuity playbook:

1. Transplant-first counseling and referral workflows.
2. Home dialysis education (peritoneal or home hemodialysis).
3. Access surgery coordination with reminders and transportation.
4. Symptom monitoring and early escalation to avoid ED spirals.

The aim is a planned start rather than a chaotic, on-the-floor initiation. “We’ve seen our planned start rate go up, the crash rate go down, and home dialysis go up,” Shaps reported. That sequence protects quality of life and bends the cost curve.

Does it work—and how do you know?

Yes—when navigation is systematic, measured, and relentlessly iterated. Healthmaps solutions uses knowledge assessments and repeats them post-education to confirm progress. As Shaps summarized, results show movement in the metrics that matter: “Planned starts up… crash rate down… home dialysis up.” Equally important, feedback loops with providers reinforce adoption: navigators bring back specific med and visit opportunities, not generic advice.

What to measure (and show your board):

1. Avoidable utilization: ED rates, admissions, readmissions per 1,000, risk-adjusted.
2. Progression markers: eGFR slope, albuminuria control, time to nephrology follow-up.
3. Treatment readiness: Access placement lead time, transplant referral rates.
4. Engagement: Answer/connect rates, refill persistence, kept-appointment rates.
5. Experience: Provider satisfaction with navigator touchpoints; member sentiment.

Report these quarterly, with trend lines and dollar translation—linking clinical wins to financial performance.

Why do behavior and culture matter as much as analytics?

Because daily choices compound more powerfully than any single prescription. “It’s hard to change behavior in a 15-minute conversation. Repetition goes a long way, and having a caring nurse goes a long way,” Shaps said. And yes, culture is candid: “Pizza and cheeseburgers taste really good—it’s hard to get somebody to stop.” Navigators add the repetition, empathy, and problem-solving that clinical teams can’t sustain between visits.

Build the culture that sticks:

• Normalize micro-touches: Short, frequent check-ins beat quarterly lectures.
• Design for frictions: Transportation, refills, copays—remove them one by one.
• Coach, don’t scold: Celebrate small wins; anchor progress to personal goals.
• Close the loop: Always bring insights back to the physician to reinforce trust.

This is where analytics becomes outcomes: when it is delivered through a human who knows the member’s name, context, and next best step.

What’s next for Healthmap—and for CKD care more broadly?

On Healthmap’s trajectory, Shaps is intentionally modest: “We’ve got our heads down—bringing on new clients, keeping clinically sound programs, staying current when new literature comes out.” Expect steady iteration, not hype cycles. For CKD broadly, Shaps points to therapy and technology tailwinds—new medications that may slow progression and improving options in dialysis access and home tech. The counter-currents are familiar: “There’s a lot of diabetes and hypertension out there… the ability to get healthy food can be a challenge.”

Watchlist for leaders:

• Medication adoption across SGLT2i/GLP-1 pathways in appropriate patients.
• Tele-nephrology and remote monitoring integrated with primary care.
• Home dialysis enablement with training and caregiver support.
• Food-as-medicine and transportation benefits that tackle SDOH directly.
• Outcome-based contracting aligned to avoidable utilization and CKD progression.

The strategic mandate is clear: keep the programs clinically rigorous and relentlessly practical.

What should payers and providers do now?

Start by focusing on avoidable acute care and readiness for the next stage. “We want patients to get the right care at the right place at the right time,” Shaps stressed. Partnering where it accelerates impact—and resisting the urge to reinvent every wheel—delivers faster gains. As he added, “The unnecessary care is where there’s a lot of opportunity.” That’s where quality, cost, and member experience converge.

An executive action plan for the next 90 days:

1. Name the metrics: Choose 3–5 outcome targets (e.g., avoidable ED, planned starts, refill persistence).
2. Stand up navigation for CKD: If partnering, pick a high-value market and launch; if building, pilot with a contained panel.
3. Embed provider loops: Send actionable member-level insights weekly, not dashboards monthly.
4. Operationalize SDOH: Budget for rides, refills, and food supports where ROI is proven.
5. Publish results: Share wins with clinicians and members—momentum compounds.