*Purpose: Transplantation is the treatment of choice for ESRD. While short-term outcomes have improved, long-term outcomes lag. Many factors may explain the long-term lag including lack of coordination between transplant centers and local nephrologists. Kaiser Permanente Northern California (KPNC) is an integrated health care system. More than 400,000 KPNC members have CKD, with 1,300 initiating dialysis and approximately 250 patients undergoing kidney transplantation annually mostly at two centers: University of California San Francisco (UCSF) and Davis (UCD). KPNC and UCSF formed a partnership and established a joint Transplant Nephrology Clinic (TNC) in San Francisco in 2007, then a second TNC in South Sacramento in 2013 to coordinate kidney transplant care.

*Methods: The two transplant centers transition care of patients to TNC 90 days after kidney transplant. TNC functions as a hub to coordinate care between transplant centers and referring nephrologists. By utilizing a shared electronic medical record system, the staff at TNC provide care in clinic and monitor immunosuppression, labs, protocol and for-cause biopsy, as well as post-transplant complications. They work in close partnership with transplant nephrologists from UCSF and KPNC referring nephrologists. In addition, TNC provides care coordination services: ancillary services management, connect patients and Transplant Centers with travel and lodging, monitor timely access to care, provide social services, track and report quality outcomes, and escalation of care to the transplant center when indicated.

*Results: The TNC follows 2882 patients and an additional 380 patients managed elsewhere were included. The department has established a standard labs and visits protocol. The compliance rate with visits is 98 % (Table 1). The long-term outcomes of this program include: 1) Acute rejection episode rate of 2.4 %, 2) For cause biopsy rate is 4.3 %, 3) Death with functioning kidney rate of 1.7 % (Table 2).

*Conclusions: The collaboration between an integrated health care system and transplant center is a model of post-transplant care.

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