Workflow GuideOsteoporosis

Osteoporosis APCM Enrollment Workflow Guide

Streamline Osteoporosis APCM enrollment with AI-driven workflows for DEXA scheduling, fall risk assessments, and chronic care management for Medicare.

Enrolling Medicare patients with osteoporosis into Advanced Primary Care Management (APCM) requires a structured approach to ensure compliance and clinical efficacy. This workflow focuses on identifying high-risk individuals, scheduling DEXA scans, and implementing secondary fracture prevention strategies through automated outreach and AI-powered patient coordination.

The Challenge

Practices often struggle to manage the high volume of Medicare-age women requiring bone density monitoring, leading to missed DEXA scans, poor medication adherence for bisphosphonates, and incomplete fall risk documentation necessary for APCM reimbursement and patient safety.

Step-by-Step Workflow

1

Identify Eligible Medicare Population

Use EHR data to flag Medicare patients with a diagnosis of osteoporosis (ICD-10 M81.0) or those with recent low-impact fractures who qualify for intensive APCM services.

Best Practices
  • Filter by gender and age to prioritize high-risk women over 65
  • Cross-reference with FRAX scores in patient charts
Common Pitfalls
  • Missing patients with osteopenia who have a high fracture risk profile
2

Automated Enrollment Outreach

Deploy AI voice assistants to call eligible patients, explain the benefits of the bone health APCM program, and obtain documented verbal consent for enrollment.

Best Practices
  • Emphasize the zero-cost preventive nature of the program
  • Use a friendly, geriatric-optimized voice profile
Common Pitfalls
  • Using overly technical medical jargon that confuses elderly patients
3

DEXA Scan Coordination

Automatically check the date of the last bone density test and schedule the next DEXA scan during the enrollment call to ensure monitoring stays within Medicare's 24-month window.

Best Practices
  • Verify the 24-month interval requirement to avoid claim denials
  • Offer immediate scheduling options during the AI interaction
Common Pitfalls
  • Scheduling scans too early for Medicare coverage eligibility
4

Fall Risk Assessment Integration

Conduct a standardized fall risk assessment via the AI platform, documenting home safety concerns, previous balance issues, and lighting conditions for the care plan.

Best Practices
  • Incorporate CDC STEADI toolkit questions into the script
  • Flag high-risk patients for immediate physical therapy referrals
Common Pitfalls
  • Failing to document specific environmental hazards mentioned by the patient
5

Medication Adherence Verification

Confirm current use of bisphosphonates or denosumab, identifying barriers such as gastrointestinal side effects or injection scheduling difficulties.

Best Practices
  • Flag patients overdue for Prolia (denosumab) injections for urgent follow-up
  • Ask about administration techniques for oral medications
Common Pitfalls
  • Ignoring minor side effects that lead to silent medication discontinuation
6

Nutritional and Lifestyle Counseling

Deliver automated education regarding calcium and vitamin D intake along with weight-bearing exercise recommendations tailored to the patient's mobility level.

Best Practices
  • Provide specific daily milligram targets for bone health
  • Suggest low-impact exercises like Tai Chi for balance
Common Pitfalls
  • Not accounting for dietary calcium vs. supplemental intake
7

Care Plan Finalization and Distribution

Generate a comprehensive APCM care plan including fracture prevention goals and transmit it to the patient and their primary care provider via secure portal.

Best Practices
  • Include a 24/7 contact number for bone health emergencies
  • Ensure the plan is written at a 6th-grade reading level
Common Pitfalls
  • Forgetting to share the care plan with the patient's entire care team

Expected Outcomes

1

Increased APCM enrollment rates for high-risk osteoporosis patients

2

Improved adherence to denosumab and bisphosphonate therapy schedules

3

Higher rates of DEXA scan completion within Medicare-approved windows

4

Reduction in secondary fracture incidents through proactive fall risk management

5

Enhanced documentation for Medicare quality measures and APCM billing

Frequently Asked Questions

While primarily for chronic conditions like osteoporosis, patients with osteopenia and a high FRAX score may qualify if they meet the criteria for intensive care management under APCM guidelines.

AI call systems track injection dates and automatically reach out to patients 14 days before their next dose to ensure scheduling and prevent dangerous therapy gaps.

Yes, Medicare allows for documented verbal consent. Our AI platform captures, timestamps, and logs this consent directly into your EHR for audit compliance.

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Osteoporosis APCM Enrollment Workflow Guide | Tile Health