Workflow GuideOsteoporosis

Osteoporosis APCM Care Plan Workflow & AI Automation

Streamline Osteoporosis APCM care plan creation with AI. Improve DEXA scheduling, fall risk assessment, and fracture prevention for Medicare patients.

Creating comprehensive APCM care plans for osteoporosis requires systematic tracking of DEXA scans, medication adherence for bisphosphonates, and fall risk assessments. This workflow leverages AI-powered call handling to automate patient data collection and ensure all Medicare requirements for bone health management are met efficiently while reducing staff workload.

The Challenge

Practices struggle to maintain bone health care plans due to the high volume of Medicare patients, complex monitoring requirements for denosumab, and the need for frequent fall risk evaluations, often leading to missed DEXA scans and preventable secondary fractures.

Step-by-Step Workflow

1

Patient Identification & Eligibility

Use AI to scan patient records for Medicare-age women and those with previous fractures to identify candidates for APCM enrollment. This ensures that high-risk patients are prioritized for bone density monitoring and chronic care management services.

Best Practices
  • Cross-reference ICD-10 codes for osteopenia
  • Check DEXA dates for two-year eligibility
Common Pitfalls
  • Overlooking male patients with high risk factors
  • Ignoring patients with secondary osteoporosis
2

Automated Intake & Fall Risk Screening

AI-driven calls collect patient history on falls, calcium/vitamin D intake, and home safety hazards before the clinical visit. This pre-populates the assessment, allowing clinicians to focus on medical decision-making during the encounter.

Best Practices
  • Use standardized questionnaires like the CDC STEADI
  • Ask about vision and balance changes
Common Pitfalls
  • Not documenting specific environmental hazards
  • Failing to record previous near-miss falls
3

DEXA Scan Coordination

Schedule bone density tests automatically based on the two-year Medicare coverage window or clinical necessity for high-risk patients. AI can handle the outreach and reminders, reducing the administrative burden on front-desk staff.

Best Practices
  • Sync with local imaging centers for availability
  • Confirm patient weight limits for DEXA machines
Common Pitfalls
  • Scheduling too early for Medicare reimbursement
  • Not confirming the scan site (hip vs spine)
4

Medication Adherence Tracking

Implement AI follow-ups for patients on oral bisphosphonates or denosumab injections to monitor side effects and compliance. Regular touchpoints ensure that patients do not miss their six-month injection windows or stop oral therapy prematurely.

Best Practices
  • Ask about dental procedures for ONJ risk
  • Verify the patient is taking oral meds with water
Common Pitfalls
  • Missing the window for Prolia injections
  • Not documenting GI side effects from oral meds
5

Secondary Fracture Prevention Integration

For post-fracture patients, initiate a specific secondary prevention protocol including physical therapy referrals and bone health counseling. AI triggers these workflows immediately following an acute event to prevent a second fracture.

Best Practices
  • Prioritize hip and vertebral fracture cases
  • Coordinate with hospital discharge planners
Common Pitfalls
  • Delayed post-discharge outreach
  • Failing to update the FRAX score after a new event
6

Care Plan Documentation & Billing

Aggregate AI-collected data into the EHR to generate a structured APCM care plan focused on bone density improvement and injury prevention. This documentation supports the monthly billing requirements for Medicare's Advanced Primary Care Management.

Best Practices
  • Use APCM-specific CPT codes
  • Include patient-specific goals for exercise
Common Pitfalls
  • Vague goal setting without measurable outcomes
  • Incomplete time-tracking for APCM requirements

Expected Outcomes

1

Increased DEXA compliance rates across the patient population

2

Significant reduction in secondary fracture incidents

3

Automated APCM documentation for streamlined billing

4

Improved patient adherence to denosumab and bisphosphonate therapy

5

Higher patient satisfaction through proactive bone health outreach

Frequently Asked Questions

AI monitors the last scan date in the EHR and automatically calls the patient when they become eligible for their biennial Medicare-covered DEXA, offering available time slots and instructions.

APCM requires a comprehensive electronic care plan, 24/7 access to care, and systematic monitoring of chronic conditions. AI facilitates this by automating outreach and data collection for bone health metrics.

Yes, denosumab requires strict 6-month dosing. AI automates the outreach two weeks prior to the due date, ensuring patients schedule their injections and maintain bone density gains.

Ready to transform your osteoporosis practice?

See how Tile Healthcare's AI call center can handle scheduling, triage, and patient communication for your practice.

Schedule a Demo
Osteoporosis APCM Care Plan Workflow & AI Automation | Tile Health