Healthcare supply typically unfolds throughout a number of scientific touchpoints, but continuity between these touchpoints can stay troublesome to maintain. Based on Rachael Rivero, nurse practitioner and proprietor of Kansas Care Join and ChronicWELL, for sufferers managing continual situations, care steadily entails a number of specialists, major care suppliers, and diagnostic pathways that don’t all the time talk in actual time.
From her perspective, these structural disconnects can go away sufferers navigating complicated remedy plans alone whereas suppliers handle rising administrative pressure. “When affected person knowledge is fragmented, follow-up between visits is proscribed, care groups are stretched skinny, and small points can escalate into preventable problems and even hospital stays,” she says.
Kansas Care Join emerged as her response to these systemic gaps. Constructed round Medicare’s Continual Care Administration framework, the group operates as a nurse practitioner-led coordination associate supporting sufferers between workplace visits. Its mannequin facilities on structured check-ins, care plan oversight, and distant affected person monitoring, designed to floor dangers earlier.
Based on Rivero, proactive monitoring permits care groups to determine modifications in situation traits, remedy adherence, or way of life components earlier than they evolve into higher-acuity occasions. Analysis has famous that structured continual care coordination applications are related to reductions in hospital admissions and improved affected person engagement, reinforcing the worth of sustained between-visit help in complicated populations.
Rivero’s pathway into this work was formed by greater than a decade of training as a nurse practitioner specializing in pulmonary, sleep, and important care. Her early scientific basis started in intensive care settings, the place she developed an appreciation for high-acuity problem-solving and interdisciplinary coordination. Over time, she expanded into the outpatient setting, the place long-term affected person relationships revealed a unique set of challenges.
“Within the ICU, you’re fixing fast crises,” she explains. “However in outpatient care, you start to see the lengthy story, what occurs between visits, what will get missed, and the way simply sufferers can really feel misplaced within the system.”
These longitudinal relationships grew to become formative. Rivero notes that many sufferers expressed confusion about remedy sequencing, follow-ups, and specialist coordination. She remembers that care plans might stall when diagnostics had been delayed, outcomes had been siloed, or communication loops remained incomplete.
“Sufferers would come again with out solutions, and suppliers had been simply as pissed off as a result of the knowledge, testing, or follow-up they wanted hadn’t come collectively in time to maneuver care ahead,” she says. “That cycle stored revealing operational blind spots, even in techniques delivering high-quality remedy.”
Drawing on each her scientific publicity and an early educational background in entrepreneurship, Rivero started exploring care coordination frameworks that would function regionally. In 2023, she noticed a chance to design a nurse-led mannequin tailor-made to neighborhood practices quite than nationwide call-center buildings. Launching Kansas Care Join required balancing full-time scientific obligations with enterprise growth and household life, but she considered the hassle as mission-aligned. From her perspective, the necessity for coordinated help outweighed the uncertainty of constructing an unbiased group from the bottom up.
Since its founding, Kansas Care Join has expanded via numerous phases. Rivero credit early development to outcomes-driven belief quite than conventional advertising and marketing channels. She explains that the connection credibility throughout the medical neighborhood performed a central position in adoption and development.
Management philosophy has additionally formed the group’s tradition. Rivero emphasizes a team-first working mannequin grounded in collaboration throughout nurse practitioners, registered nurses, and help employees. “No position is extra essential than one other,” she explains. “We perform as one care staff, and the work solely succeeds when everybody feels possession within the mission.” She pairs that philosophy with versatile buildings that enable many clinicians, notably working dad and mom, to function in hybrid or distant codecs whereas sustaining continuity for sufferers.
Compassion and accountability stay core pillars. Rivero notes that many staff members had been drawn to the group via private caregiving experiences, reinforcing empathy as a hiring lens. She believes these shared motivations translate into deeper affected person rapport and sustained engagement, notably for people managing a number of continual situations.
Wanting forward, Rivero’s long-term imaginative and prescient extends via ChronicWELL, a broader ecosystem designed to help people dwelling with continual illness past conventional coordination companies. She explains the initiative as a community mannequin encompassing training, wellness assets, and extra care pathways aimed toward serving to sufferers preserve high quality of life alongside scientific remedy.
Rachael Rivero’s journey from important care clinician to healthcare founder displays an effort to shut operational gaps she witnessed firsthand. By way of Kansas Care Join and the growing ChronicWELL platform, Rivero continues to construct fashions centered on coordination, continuity, and human connection, rules she believes stay important as continual care wants broaden nationwide.
