Workflow GuideACOs (Accountable Care Organizations)

ACO Chronic Care Monthly Check-In Workflow & MSSP Optimization

Optimize ACO chronic care monthly check-ins to boost MSSP shared savings, improve quality measures, and reduce total cost of care with AI automation.

Effective monthly chronic care check-ins are the engine of ACO success, directly impacting MSSP shared savings by reducing hospitalizations and closing care gaps. This workflow leverages AI-powered automation to scale Advanced Primary Care Management (APCM) across your entire provider network, ensuring consistent patient engagement and data capture for risk-based contracts.

The Challenge

ACOs struggle to scale monthly check-ins across diverse participating practices, often missing critical interventions that lead to avoidable ER visits and failing to document the quality measures necessary for maximum shared savings.

Step-by-Step Workflow

1

Identify High-Risk Beneficiaries via AI Stratification

Use AI to analyze claims data and EHR records to prioritize beneficiaries with multiple chronic conditions who are most likely to benefit from monthly APCM outreach.

Best Practices
  • Focus on patients with recent hospital discharges
  • Integrate risk scores into the dialer
Common Pitfalls
  • Manual list generation which is slow and error-prone
2

Automated Outreach for Care Plan Review

Deploy AI voice agents to conduct the initial monthly check-in, reviewing the existing care plan and identifying any new symptoms or medication changes.

Best Practices
  • Use HIPAA-compliant AI voice
  • Allow for seamless human handoff
Common Pitfalls
  • Using robotic text-to-speech that patients ignore
3

Real-time Care Gap Identification

During the call, the AI cross-references the patient's profile with ACO quality measures like A1c checks or flu vaccines to identify and close gaps.

Best Practices
  • Script specific quality measure questions
  • Update the care plan in real-time
Common Pitfalls
  • Failing to document gap closure during the call
4

Medication Reconciliation and Adherence Check

The AI agent confirms the patient is taking medications as prescribed and flags any potential side effects or barriers to adherence for clinical review.

Best Practices
  • Ask about cost barriers to meds
  • Sync with pharmacy data
Common Pitfalls
  • Assuming adherence without direct patient confirmation
5

Social Determinants of Health (SDOH) Screening

Screen for transportation, food security, or housing issues that might impact the patient's ability to manage chronic conditions effectively.

Best Practices
  • Standardize SDOH questions
  • Route flags to ACO social workers
Common Pitfalls
  • Ignoring non-clinical factors in the care plan
6

Automated Documentation and Billing Capture

The AI generates a detailed encounter note that maps directly to APCM billing codes and ACO quality reporting requirements, pushing it to the EHR.

Best Practices
  • Ensure time-stamped documentation
  • Include all relevant CPT codes
Common Pitfalls
  • Incomplete notes that don't meet CMS audit standards
7

Escalation of High-Risk Clinical Triggers

Immediately route any patient reporting red-flag symptoms or significant health declines to the ACO's central clinical triage team.

Best Practices
  • Define clear clinical escalation protocols
  • Use warm transfers
Common Pitfalls
  • Delayed response to acute symptom reporting

Expected Outcomes

1

Increased MSSP shared savings through reduced ER visits

2

Higher performance on ACO quality measures

3

Scalable APCM revenue across the entire provider network

4

Improved beneficiary engagement and satisfaction scores

5

Lower total cost of care for high-risk populations

Frequently Asked Questions

APCM provides a predictable fee-for-service revenue stream while simultaneously lowering the total cost of care, which increases the shared savings pool for the ACO.

Yes, AI can be programmed with clinical logic to handle routine check-ins and identify when a patient needs to speak with a licensed clinician.

A centralized AI-powered platform standardizes the outreach and documentation process across the entire ACO network, regardless of the local practice EHR.

CMS requires at least 20 minutes of non-face-to-face care management per month, including a care plan review and documentation of all interventions.

Ready to transform your acos (accountable care organizations) practice?

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

Schedule a Demo
ACO Chronic Care Monthly Check-In Workflow & MSSP Optimization | Tile Health