Interventions for Promoting Kidney Transplant Empowerment

Inclusion Criteria: * Patient inclusion: * Provision of signed and dated informed consent from the patient. * Stated willingness to comply with all study procedures and availability for the duration of the study. * Age 18 - 75 years * eGFR≤20 mL/min/1.73m2 or on maintenance in-center HD. * Receive kidney care at Mount Sinai, Einstein, Bellevue Hospital, NYU, or hemodialysis at a participating HD Center. * Community dwelling (i.e., not in a nursing home, currently incarcerated). * Speak English and/or Spanish. * Provider Inclusion: * Provision of signed and dated informed consent from the nephrologist. * Stated willingness to comply with all study procedures and availability for the duration of the study. Exclusion Criteria: * Patient Exclusion: * Absolute contraindications to KTx: * Self-reported or documented diagnosis of dementia, or inability to understand the study and complete informed consent. When the participant's understanding is unclear, the CRC will use a modified MOCA screener to determine eligibility. * Active malignancy (excluding local non-melanoma skin cancer, renal cell carcinoma \<5 cm, early thyroid cancer, and prostate cancer GS≤6). * Pregnancy (can be re-evaluated post-delivery). * Active infection. Patients excluded due to active infection will be evaluated at 30 days or after completing full treatment (whichever is later) to determine eligibility. Examples of active infection include: * Positive cultures or radiographic evidence of infection * Infected intravascular devices, such as tunneled catheters and pacemakers * Active histoplasmosis, cryptococcosis, tuberculosis (TB), and nontuberculous mycobacteria * Previously evaluated by KTx and not listed for specific medical reasons. * Patients previously evaluated and not listed will be carefully reviewed by site PI for eligibility * Already listed for KTx. * Patients on other types of dialysis other than in-center hemodialysis. * Self-identify as already engaged with a CHW at participating sites to address unmet social needs. * Planning to move out of the greater NY area in the next 1 year. * Provider Exclusion: * Planning to leave their respective institutions in the next 1 year