Chronic Kidney Disease (CKD) affects more than 1 in 7 adults in the United States (US) and leads to significant morbidity, mortality, and use of scarce healthcare resources. Despite the high prevalence of CKD, as many as 9 in 10 people with CKD are unaware of their disease. According to the Center for Disease Control (CDC) Behavioral Risk Factors Surveillance System, West Virginia (WV) is ranked as the least-healthiest state in the U.S. with 4.6% of the population having CKD. No existing research studies are available to understand disease burden and healthcare utilization by CKD patients for West Virginians. This proposed project aims to improve the health status and literacy by identifying gaps in evidence-based care and the associated increased use of healthcare resources, particularly within the under-served population in WV. We propose to develop a novel Artificial Intelligence (AI) tool that will incorporate CKD patient-specific big data in an actionable way to minimize CKD progression, address health disparities at a local level, and provide a construct to deliver care in a more efficient and sustainable manner.