Nephrology APCM Implementation Checklist | Tile Healthcare

Filter your EHR for patients with eGFR below 45 who are not yet on dialysis for APCM eligibility.

Focus enrollment on patients with concurrent diabetes and hypertension to reduce the risk of rapid progression.

Obtain verbal or written consent for APCM services and ensure it is time-stamped within the patient record.

Designate a staff member to oversee Stage 4-5 transitions and transplant referral status updates.

Establish clear, patient-specific targets for GFR stabilization and blood pressure control in the care plan.

Review all renally dosed medications and check for contraindicated NSAID use during monthly check-ins.

Set up AI triggers to follow up with patients immediately after lab results show critical potassium or phosphorus levels.

Track ESA therapy adherence and monitor hemoglobin levels to ensure patients stay within target ranges.

Integrate remote monitoring data to identify hypertensive trends that could accelerate kidney damage.

Use AI voice check-ins to monitor for edema or rapid weight changes that suggest fluid overload.

Use automated voice assistants to conduct weekly check-ins on low-potassium and low-sodium diet compliance.

Screen patients for nausea, pruritus, or metallic taste using AI triage to catch late-stage CKD complications.

Automate reminders for transplant work-up appointments and document waitlist status updates.

Ensure Stage 4-5 patients receive automated follow-ups for fistula mapping and surgical consults.

Streamline refill requests for phosphate binders and renal vitamins through an AI-powered phone menu.

Ensure all non-face-to-face time, including AI-driven monitoring review, is logged for APCM billing.

Maintain a structured plan for the transition from CKD management to dialysis or transplant.

Verify that all care plans align with the latest KDIGO clinical practice guidelines for CKD management.

Ensure the APCM care plan is accessible to all clinicians involved in the patient's renal care team.

Document communication with dialysis centers for patients in the 'crash' prevention phase.