APCM Implementation Checklist for Osteoporosis

Use EHR filters to find patients with Z87.310 or M81.0 codes for targeted outreach and APCM enrollment.

Use AI-powered calls to explain APCM benefits and capture verbal consent for billing purposes and care coordination.

Implement an AI answering service that can triage urgent bone health issues and fracture concerns after business hours.

Ensure the 10-year probability of fracture is documented in the electronic care plan for all enrolled osteoporosis patients.

Verify that patients can view their osteoporosis management plan via a secure portal or receive a mailed hard copy.

Use automated reminders to ensure patients take oral medications correctly on an empty stomach to maximize absorption.

Set up 6-month automated triggers to schedule denosumab injections before the therapeutic window closes and bone loss occurs.

Conduct quarterly AI check-ins to verify patient adherence to prescribed calcium and vitamin D3 supplementation protocols.

Use natural language processing during calls to identify patient reports of atypical femur pain or symptoms of osteonecrosis.

Schedule routine metabolic panels to monitor renal function and calcium levels during active pharmacological therapy.

Automate outreach for biennial bone density scans based on Medicare's 24-month eligibility rule for osteoporosis monitoring.

Deliver automated instructions regarding calcium intake and clothing requirements 24 hours prior to DEXA appointments.

Perform structured assessments over the phone using standardized questions to identify environmental hazards and balance issues.

Coordinate with local PT clinics for patients identified as high-risk for falls during their monthly APCM screening.

Provide a verbal checklist of home modifications, such as grab bars and lighting, to reduce fracture risk in the home.

Enroll any patient with a recent fragility fracture into a specialized APCM monitoring track for intensive follow-up.

Initiate AI calls within 48 hours of hospital discharge to coordinate bone health recovery and medication changes.

Ensure communication between orthopedic surgeons and primary care regarding long-term bone density pharmacological plans.

Incorporate specific physical activity goals and resistance training into the chronic care management documentation.

Provide resources on bone-healthy diets and protein intake as part of the monthly APCM educational requirement.