AFib Chronic Care Enrollment Checklist | TileHealthcare

Ensure there is a confirmed diagnosis via 12-lead ECG or monitor in the EHR to meet medical necessity for chronic care enrollment.

This score is vital for determining the necessity of anticoagulation and must be updated annually as patient risk factors change.

Document bleeding risk to balance the benefits of anticoagulation against potential complications, especially in elderly patients.

Document the current clinical approach and any history of cardioversion or ablation procedures to tailor the monitoring plan.

Identify associated conditions like OSA, thyroid dysfunction, and CKD that may impact AFib management and drug metabolism.

Specify Warfarin vs. DOAC (Apixaban, Rivaroxaban) and ensure dosage aligns with renal function and age parameters.

For Warfarin patients, set automated reminders for lab visits via AI call handling to prevent gaps in therapeutic range.

Check for recent major bleeds or planned surgeries requiring bridge therapy to avoid adverse event occurrences.

Ensure up-to-date contact information for automated refill reminders and prior authorization status management.

Use AI-driven check-ins to identify barriers to daily DOAC compliance and provide patient education on stroke risks.

Set 3, 6, and 12-month recurrence monitoring milestones for surgical patients to ensure long-term procedure success.

Clearly define when palpitations, dizziness, or shortness of breath require immediate clinical escalation or triage.

Set parameters for automated phone systems to flag high-risk AFib symptoms directly to the nursing staff for review.

Automate appointment scheduling for periodic cardiac structure and rhythm assessment via integrated AI voice reminders.

Ensure all non-face-to-face patient interactions are logged for Advanced Primary Care Management billing requirements.