Historically, Monogram Health’s flagship area of expertise was based on kidney health. But the polychronic nature of this patient population has made it clear that healthcare professionals cannot focus on just one organ or disease, because every organ relies on the other for optimal functionality.
For example, diabetes is the biggest killer of kidneys in this country with obesity as a major contributing factor. But we must think even more broadly than that: Obesity itself brings the comorbidities of hyperlipidemia, hypertension, and progressive vascular dysfunction, all of which affects the blood vessels, including the small collections of capillaries in the kidneys – the glomeruli – which support all the filtering work of the body, thus contributing to chronic kidney disease (CKD). These disease processes together lie at the root of an increasingly recognized malady called cardio-kidney metabolic syndrome (CKM).
That’s why over time, Monogram Health’s focus has expanded beyond kidney health alone. Instead, we have a holistic, multi-specialty view of polychronic patients. With a high-touch, algorithm-based, in-home approach to nephrology, we are embracing a new era and paradigm of combination therapies, data analysis, and holistic care—with the ultimate goal of not just slowing kidney disease progression but actually achieving clinical remission of the CKM process.
An Algorithmic Approach
A unique aspect of Monogram Health’s in-home nephrology model identifies patients who are excellent candidates for certain interventions, such as kidney transplant, dialysis, or therapies maximized for heart failure or diabetes. Once a treatment is identified, our challenge – or battle cry – resides in managing the nuances associated with each individual patient’s unique clinical needs. Our solution is a set of evidence-based algorithms that guide our multi-specialty, in-home healthcare teams. These algorithms show how to think about patients and what questions to ask in order to direct medical therapy in a way that’s helpful and safe, empowering clinicians to take immediate action and bring in additional sub-specialties as needed.
Take for example the algorithm we have developed for resistant hypertension. It is designed to ensure blood pressure is at goal, and walks the clinician through a series of inquiries including – what combination of medications they are taking, if their blood pressure has been checked correctly, if they are adhering to their medications and refilling prescriptions correctly, if they have any barriers to obtaining/taking their medications, and if they are eating a low sodium diet, etc. Once these factors have been addressed, and if the individual still has high blood pressure, only then can a diagnosis of resistant hypertension be confirmed, which is actually only a fraction of those who were labelled as such before our clinician’s involvement. The second phase of the algorithm is designed to diligently look for secondary causes of resistant hypertension, the treatment of which can be uniquely supported by our in-home subspecialty teams. For patients that do not have an additional secondary problem contributing to their high blood pressure, the local teams are able to take an evidence and guideline-based approach to prescribing medications in a targeted way to achieve blood pressure control. Putting this process into practice, we recently had a case where an individual had persistent hypertension despite trialing various combinations of six different blood pressure medications, with a rising side effect profile. Not only was his blood pressure out of control, but he already had two strokes and CKD stage 4 and was only in his mid-fifties. Following the algorithm, and with support of both our nephrology and endocrinology specialty teams, our Advanced Practice Provider (APP) accurately diagnosed him with hyperaldosteronism, which is caused by over-activity in both of his adrenal glands. Once we identified the root of the problem, we were able to get his blood pressure under control, reduce further cardiovascular and kidney risk, and decrease his antihypertensive medication burden to two drugs with lower side effect profiles. Utilizing our evidence-based order sets and algorithms, one of our APPs made a life-changing diagnosis for this individual in a streamlined and evidence-based way.
The In-Home Edge
Over my time at Monogram, I have led and trained regional teams including physicians, social workers, nurses, and APPs, and I have experienced first-hand the true impact of being in the home. Getting to see a patient’s lifestyle in action is invaluable knowledge that can equip our clinicians with an additional layer of insight into how a patient is adhering (or not adhering) to their treatment plan(s). Being in the home enables our clinicians to have more meaningful conversations, course correct daily routines (such as medication dosage, sanitation, diet assistance, or fall prevention), as well administering additional tests on the spot that might bring in additional sub-specialties (such as cardiology, endocrinology, pulmonology, palliative care or social workers). As in the example above, both nephrology and endocrinology were mobilized to help the individual with resistant hypertension. In other situations, our cardiology or pulmonary subspecialists are called in to potentially tease out the cause of ongoing shortness of breath in someone with both lung disease and heart failure. If a patient is having trouble sourcing or paying for their medication, we can bring in our social workers and/or pharmacists to identify solutions. As it pertains to nephrology, soon we will be able to test in-home for albumin in the urine, giving our multi-specialty APPs a head start on identifying those at an increased risk for progression of kidney disease and creating the appropriate treatment plan for slowed progression and/or potential remission.
This high-touch approach is also demonstrated when patients need extra support but are not ready for hospice. That is when our palliative care team comes in to address issues like advance care planning, conservative management options, symptom burden and caregiver support. As a true value-based-care company, everything Monogram does is based on what’s good for the patient including both acute and longitudinal treatment and care.
The Next Frontier
Since inception, Monogram’s nephrology program has yielded exceptional results. In 2025 alone, Monogram saw a 35% reduction in hospital admissions and 44% fewer re-admissions. The longer a patient is with monogram, the more benefit they receive, with 64% starting dialysis as an outpatient and 55% starting dialysis in an optimized way (with a permanent dialysis access) with those under Monogram’s care for 48 months. For patients under Monogram’s care at the time of dialysis initiation, more than 30% of our population is doing home dialysis within 6 months. Across the country, these results are well above the national average; according to the USRDS database in 2023, 28% of patients had an optimized start and 15% initiated with a home dialysis modality.
Looking beyond the historical goal of delaying the inevitable loss of kidney function, Monogram is looking to halt the decline of kidney function to normal healthy aging. A critical component to this pathway is the introduction of disease-slowing medications. Monogram is leveraging its patient population data to track the “four pillars” of diabetic kidney management—SGLT2 inhibitors, GLP-1s, ACE inhibitors/ angiotensin II receptor blockers (ARBs), and non-steroidal mineralocorticoid receptor antagonists (nsMRAs) like Finerenone. Leveraging our data, we can now identify patients who could benefit from these combination medications, and work with their clinical team to get them started.
This proactive approach can be extremely impactful as approximately 14% of the U.S. adult population has chronic kidney disease, but the vast majority of people die of something other than their CKD. What our high-touch, data-rich model has shown is that dealing with kidney health means changing the approach from merely slowing down the progression of kidney disease to possible clinical remission. With combination therapies, this is now a realistic goal, as studies have demonstrated that the annual rate of eGFR decline has improved dramatically as therapies like SGLT-2s, GLP-1s and nsMRAs have been combined with ACE inhibitors and ARBs, benefiting not only the kidneys, but all the other organs ravaged by the cardio-kidney metabolic syndrome.
Looking back at my career, when I began my training as a nephrologist fellow, we just had to accept while we could try to slow down diabetic CKD progression, over time, the surviving individuals would eventually succumb to end-stage kidney disease and therefore need dialysis. Today, at Monogram, we don’t have to accept that dogma, and instead, are fully embracing and actively contributing to doing more so our polychronic patients can lead healthier, happier, and more fulfilling lives.
Attributed to: Mindy Banks, M.D., Chief Nephrologist at Monogram Health
This article was published on Beckers Hospital Review on May 14, 2026.
