Care coordination and case management services for patients with chronic kidney disease (CKD), patients that are post-kidney transplant, and patients undergoing dialysis, including diabetes and high blood pressure management; care coordination in preparation of dialysis, including access placement; data analysis to identify patients with undiagnosed CKD and related diseases; providing personal support services for patients, namely, meetings with patients to determine each patient's unique care goals and objectives, formulating a care plan for each patient, updating the care plan as the patient's needs or goals change, all in the field of chronic kidney disease (CKD); medication therapy review and facilitating any needed changes medication regimen, all in the field of chronic kidney disease (CKD); training and coordinating care in the areas of lifestyle choices, preemptive transplant, dialysis modality, dialysis options and medical management without dialysis, all in the field of chronic kidney disease (CKD); services rendered by social workers, namely, mental health and social needs assessments, evaluations, and referrals, all in the field of chronic kidney disease (CKD); dietician services, all in the field of chronic kidney disease (CKD); pharmacist consultation services, all in the field of chronic kidney disease (CKD); and consulting services in the field of nursing, all in the field of chronic kidney disease (CKD); all of the foregoing excluding services in the field of gene therapy