Support for advanced heart/lung/kidney disease
At TidalHealth, our Support for Advanced Heart, Lung and Kidney Disease program is thoughtfully designed for people living with severe heart, lung or kidney conditions. We aim to help you manage symptoms, maintain function and find more comfort in daily life. Our multidisciplinary team may include cardiologists, pulmonologists, nephrologists, advanced practice providers, palliative care clinicians, nurses, social workers, pharmacists, nutritionists, physical and occupational therapists and care coordinators. Together, our team works closely with you and your family to create a care plan that is just right for you.
What does our support include?
- Relief of symptoms such as breathlessness, fatigue, swelling, pain and nausea
- Review and adjustment of medications
- Education about your condition and self-care tips
- Conversations and planning around your goals of care
- Support for dialysis or transplant evaluations or referrals when appropriate
- Rehabilitation and exercise guidance
- Support for the emotional, social and practical aspects of care for both patients and caregivers
- Assistance with home health, medical equipment or connecting with local community resources
Depending on your needs, services may be provided in the clinic, in the hospital, at home or through telehealth visits.
Why we offer this service
Living with advanced organ disease can bring complex symptoms and frequent hospital visits. Our program is here to help reduce unnecessary hospital stays, ease symptoms, support your day-to-day activities and make sure your care fits your values and wishes. This support works alongside your existing specialty care, helping you stay connected to your regular heart, lung or kidney specialists.
What to expect
When you join our program, you will start with a thorough assessment of your medical history, current symptoms, medications, support and goals. From there, our team will work with you to create a personalized plan, which may include medication changes, symptom management tools, exercise and nutrition recommendations, referrals for further support and a clear schedule for follow-up. You and your family will receive written guidance for managing symptoms at home and a dedicated contact for questions or help if symptoms change.
What happens after you join?
Many people find that they feel better, have clearer plans for managing their condition and need fewer emergency visits. Our ongoing care focuses on monitoring symptoms, adjusting treatment as needed and supporting your independence. For some, we focus on stabilizing your condition and maximizing quality of life. For others, we support you as you consider options like transplant or dialysis. Through it all, our team is here to discuss your wishes and help prepare for changes in care, always ensuring your comfort and peace of mind.
Who is eligible for this support program?
Patients with advanced heart failure, chronic lung disease such as COPD or pulmonary fibrosis, or advanced kidney disease including those approaching or on dialysis may be eligible. Eligibility criteria may vary, and referrals can come from your primary care clinician, a specialist, a hospital team or you and your family.
How do I get referred or enroll?
You can ask your primary care provider or specialist to refer you, or contact TidalHealth's intake coordinator directly. Many programs accept direct inquiries from patients or families and will schedule an initial assessment for you.
Will this support replace my specialist care?
No. This service works alongside your existing cardiology, pulmonology or nephrology care. Our team coordinates with your specialists to help manage symptoms, support your quality of life and provide a complete care plan.
Will participating affect my options for transplant or dialysis?
Participating in our program does not remove options for transplant or dialysis. Coordinated care and symptom management can support readiness for evaluation. If you are being considered for transplant or dialysis, our team will stay in contact with the programs to support the process.
What services may be available at home or through telehealth?
Depending on your needs, TidalHealth may offer home visits by nurses or therapists, remote monitoring, telemedicine visits, help with medication management and coordination with home health agencies. Services depend on your situation and program availability.
How soon can I expect help after I ask for services?
Timing can vary. Some teams can arrange an initial visit within a few days if needs are urgent, while routine assessments may take longer. The intake team will provide an estimated timeline.
How are symptoms like breathlessness, swelling and fatigue managed?
Management is tailored to your needs and may include medication changes, breathing techniques, pacing activities, physical therapy, oxygen therapy when needed and education on managing fluids or salt. The goal is to lessen symptoms while minimizing side effects.
Will my insurance cover these services?
Coverage depends on your insurance and services needed. Many clinical visits, home health services and telehealth visits are covered by Medicare and commercial insurers, though prior authorization or co-payments may be required. Administrative staff can help check coverage and explain costs.
What should I do if symptoms suddenly get worse?
For severe shortness of breath, chest pain, fainting, uncontrolled bleeding or other life-threatening symptoms, call emergency services or go to the nearest emergency department. For less urgent but concerning changes, contact your care coordinator or the after-hours line.
How are caregivers involved?
Caregivers are a central part of your plan. Our team provides education, support for caregiving tasks, access to respite care and help finding community resources. Advance care planning conversations can also include caregivers as you wish and with your permission.
