Management · Program 02

Care That Knows
Your Name

Multidisciplinary NCD consultations in a peaceful, respectful environment — unhurried, thorough, and truly person-centred

In most Kenyan health facilities, an NCD patient sees a different clinician at every visit, waits hours for a five-minute consultation, and leaves with a prescription but no plan. The Kenya NCD Resource and Support Center is built on a fundamentally different model — one where a dedicated, multidisciplinary team knows each patient by name, understands their full health picture, and delivers coordinated, continuous care that evolves with them over time.

1integrated care plan per patient
Teamof specialists — in one place
Telemedicine for remote specialist access
0lost referrals or missed follow-ups
What This Program Does

A Team That Stays With You

Consultations and Coordinated Care is the clinical heart of the Kenya NCD Resource and Support Center. It provides comprehensive, ongoing NCD consultations delivered by a permanent multidisciplinary team — and backed by visiting volunteer specialists and telemedicine access to consultants in Nairobi and beyond.

Each patient receives a comprehensive initial assessment — medical history, physical examination, review of diagnostic results, psychosocial screening, and nutritional evaluation — from which a personalised, integrated care plan is developed. That plan is reviewed and updated at every subsequent visit, with all team members contributing their perspective.

For complex cases requiring specialist care — cardiology, oncology, nephrology, endocrinology — the Center maintains structured telemedicine partnerships and formal referral agreements with county and national facilities. The patient is never handed off and forgotten. The Center's team accompanies them through the referral process, communicates with the receiving facility, and resumes care when they return.

Consultations and coordinated care
A team that knows your name and your story
The Care Team

Every Discipline, One Team

The power of coordinated care is that no dimension of a patient's NCD journey is handled by a single professional in isolation. Every care plan is the product of a whole team — working together, not in silos.

🩺PhysicianMedical assessment, diagnosis, medication management and overall care coordination
👩‍⚕️NCD NurseOngoing monitoring, patient education, medication administration, and care continuity
🥗NutritionistDietary assessment and personalised nutritional plans tailored to condition, budget, and local foods
🏃PhysiotherapistPhysical function assessment, rehabilitation planning, and integration of movement into care
🧠CounselorPsychosocial screening, mental health support, and behavior change guidance
📱SpecialistsVisiting consultants and telemedicine access to cardiologists, oncologists, and other specialists
Care process and consultation
Every visit builds on the last
How a Consultation Works

Unhurried, Thorough, and Planned

1

Arrival & Records Review

Patient records, previous diagnostic results, and care plan progress reviewed by the nurse before the consultation begins — ensuring the doctor is fully briefed and the visit can focus on what matters.

2

Comprehensive Assessment

Physical examination, symptom review, medication adherence check, and psychosocial wellbeing screening — unhurried, in a private, comfortable consultation room.

3

Team Discussion & Plan Update

Clinician, nurse, and relevant specialists review the assessment together and update the integrated care plan — adjusting medications, investigations, referrals, and lifestyle targets as needed.

4

Patient Education & Handover

Plan clearly explained to the patient, written summary provided. Next appointment scheduled before leaving. Pharmacy, physiotherapy, or nutrition visits coordinated on the same day where possible.