Background

Chronic kidney disease (CKD) is common in the United States and affects about one in five Veterans, whether they live in urban or rural areas. Veterans with CKD benefit from seeing a kidney specialist (nephrologist) because careful treatment of related conditions like diabetes, high blood pressure, and immune mediated kidney disease can slow kidney damage and lower the risk of kidney failure, heart disease, and death.

Slowing the progression of kidney disease and preventing kidney failure improves Veterans’ quality of life and reduces health care costs by delaying or avoiding the need for dialysis or kidney transplant.

Most nephrologists practice in large cities near academic medical centers, dialysis units, transplant centers, and large VA medical centers. Many Veterans in rural or highly rural communities receive care at smaller VA facilities that may not have a nephrologist on staff or rely on a part time specialist to care for many Veterans. Rural Veterans also have limited access to community kidney specialists, and wait times for routine nephrology appointments can be six to nine months or longer in many health care “deserts.”

Goals and Objectives

The National Telenephrology Hub and Spoke Network Enterprise Wide Initiative (EWI) was created to connect rural Veterans with CKD and high blood pressure to VA based nephrologists using telemedicine.

The program uses a “hub and spoke” model. A hub is a larger VA medical center where nephrologists work. Spokes are smaller Community Based Outpatient Clinics (CBOCs) and VA facilities linked to the hub. Through this network, nephrologists at hub sites in Boston, Massachusetts; New Haven, Connecticut; Providence, Rhode Island; Indianapolis, Indiana; Palo Alto, California; and Little Rock, Arkansas provide specialty CKD care to rural Veterans across the country.

The main objectives are to:

• Give rural Veterans timely access to kidney specialists without long travel or long wait times.
• Provide consistent, evidence based care for CKD and hypertension across VA facilities.
• Support local VA clinicians so they can confidently manage kidney disease in partnership with nephrologists.
• Reduce the need for dialysis and kidney transplant by slowing the progression of kidney disease.

Methodology

The Telenephrology EWI team first identified nephrologists at hub facilities and then built a network of interfacility consultations and clinics. Through this coordination, VA facilities without nephrologists could create specialty kidney clinics to care for Veterans with CKD or high blood pressure.

Program leaders worked closely with the VHA National Kidney Program to develop standard operating procedures for telenephrology. These procedures make sure that:

• All care is delivered by properly credentialed specialists.
• Treatment follows evidence based clinical guidelines.
• All telemedicine safety and privacy requirements are met.

Where possible, the Telenephrology EWI is staffed by locally based nurse practitioners (NPs) who serve as “local kidney champions.” These NPs are trained and supervised by hub nephrologists to:

• Review and prioritize CKD consults before Veterans’ appointments.
• Respond to urgent concerns or emergencies between visits.
• In some facilities, see Veterans independently, with the option to consult the hub nephrologist about complex cases.

This structure gives Veterans who prefer in person visits a local option while still connecting them with nephrology expertise.

The Telenephrology team also includes renal pharmacists who work with nephrologists, the VHA Kidney Medicine Program, and spoke sites to:

• Develop standardized treatment processes for kidney disease and its complications.
• Adjust medications after appointments to help Veterans reach blood pressure and diabetes targets.
• Educate pharmacists at spoke sites about medications for rare kidney diseases and coordinate infusion therapies when needed.

By integrating renal pharmacists into the care team, the program increases nephrologist productivity and helps ensure that Veterans receive safe, effective medication management.

Impact on Rural Veteran Health

In 2024, the Telenephrology EWI provided care to 3,386 Veterans, most of whom lived in rural or highly rural areas. Telenephrologists completed more than 5,000 in person or telemedicine visits for Veterans with many types of kidney disease.

Hub and spoke teams cared for Veterans with kidney problems related to diabetes, heart failure, kidney stones, and high blood pressure, as well as rare autoimmune and cystic kidney diseases. Renal pharmacists conducted 896 follow up encounters to optimize medication use and adherence. Veterans at all stages of kidney disease were treated, including Veterans with kidney transplants. (Dialysis care itself is provided through community dialysis centers and is not part of this program.)

Key outcomes include:

• Rural Veterans now have easier access to nephrologists without traveling long distances to large urban VA or university centers. In many cases, telenephrologists work directly with local VA and community providers to improve kidney care.
• Veterans report that telenephrology video visits are easy to use, informative, and thorough. They feel their care is well coordinated with local services.
• Veterans receiving telenephrology care have similar or better survival compared with those seen only by local providers. For example, annual survival was about 95% with telenephrology versus 93% with local care alone, and Veterans in the program were more likely to receive recommended therapies that slow CKD progression.
• Clinicians at spoke sites report high satisfaction and are enthusiastic about referring Veterans. They value that treatment recommendations align with the resources available at their local facilities.
• When Veterans need surgery to prepare for dialysis or chemotherapy to prevent kidney disease progression, telenephrologists can often keep this care within the VA system, which is more convenient for many Veterans.

Key Takeaways

• The Telenephrology EWI uses telemedicine to ensure that rural Veterans with CKD or difficult to control high blood pressure can see expert nephrologists and receive state of the art treatment, no matter where they live or what type of kidney disease they have.
• Since it began in 2022, the program has grown quickly and is well liked by both Veterans and local providers. Nephrologists at seven large VA hubs now provide kidney care through the network to Veterans in 20 states.
• The program supports primary care nurse practitioners and physicians who may have limited experience managing complex kidney disease, so that all Veterans receive up to date care. The goal is to stabilize kidney function with medications and monitoring so that dialysis or transplant are rarely needed.
• Because kidney disease is a long term condition, telenephrologists focus on continuity of care over many years to help maintain improvements and prevent progression to kidney failure.

Download the Printable PDF for Healthcare Providers and Researchers.

References

• Centers for Disease Control and Prevention. Tracking and Preventing Kidney Disease in America. Kidney Disease Surveillance System. Available from: https://nccd.cdc.gov/CKD/default.aspx.
• Shubrook J. H., Neumiller J. J., Wright E. Management of chronic kidney disease in type 2 diabetes: screening, diagnosis and treatment goals, and recommendations. Postgraduate Medicine. 2022;134(4):376–387.
• Saran R., Pearson A., Tilea A., et al. Burden and cost of caring for US Veterans with CKD: initial findings from the VA Renal Information System (VA REINS). American Journal of Kidney Diseases. 2021;77(3):397–405.
• Mattocks K. M., Kroll Desrosiers A., Crowley S., et al. Using RE AIM to examine implementation of a tele nephrology program for Veterans living in rural areas. Frontiers in Health Services. 2023;3:1205951.

Contact

• Program Contact: Ramon Bonegio, MD, Associate Chief of Nephrology, Renal Section, Department of Medicine, VA Boston Healthcare System, Boston, MA. Ramon.Bonegio@va.gov
• Funding Acknowledgement: Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health, NOMAD #PRFY-00541.
• Suggested Citation: Bonegio, R. G. B., Mattocks, K. M., Kroll Desrosiers, A., & Moore, D. (2025). The National Telenephrology Hub and Spoke Network. Department of Veterans Affairs, Veterans Health Administration. Washington, DC: Office of Rural Health.

Rural Health - Navigation

• Office of Rural Health Home page:
  https://www.ruralhealth.va.gov/index.asp
• Enterprise-Wide Initiatives (EWI) page:
  https://www.ruralhealth.va.gov/Enterprise-Wide-Initiatives-EWI.asp
• Veterans Rural Health Resource Centers (VRHRC) page:
  https://www.ruralhealth.va.gov/Veterans-Rural-Health-Resource-Center-VRHRC.asp