Workflow GuideEndocrinology

Endocrinology Chronic Care Monthly Check-In Workflow

Optimize Endocrinology APCM with this monthly check-in workflow. Automate diabetes monitoring, insulin titration, and TSH follow-ups via AI.

Effective endocrinology care requires consistent touchpoints beyond the quarterly office visit. This workflow leverages AI-driven call handling to automate monthly check-ins for diabetes, thyroid, and metabolic patients, ensuring APCM compliance while improving A1C and TSH outcomes through proactive monitoring and medication adherence tracking.

The Challenge

Manual outreach for thousands of diabetic and thyroid patients is labor-intensive, leading to missed APCM revenue, poor insulin adherence, and delayed TSH adjustments. Staff burnout and high call volumes often result in reactive care rather than proactive metabolic management.

Step-by-Step Workflow

1

Automated Patient Stratification

Identify high-risk patients using EHR filters for Type 2 Diabetes, metabolic syndrome, and chronic thyroid conditions. Focus on those meeting APCM criteria of two or more chronic conditions expected to last at least 12 months.

Best Practices
  • Use ICD-10 codes E11.9 and E03.9 for primary filtering
  • Review G-codes for APCM billing eligibility
Common Pitfalls
  • Ignoring patients with only one condition who may have undocumented comorbidities
2

HIPAA-Compliant AI Outreach Initiation

Deploy AI voice agents to conduct the monthly call. The AI verifies patient identity and explains the purpose of the check-in, ensuring the patient is comfortable discussing their endocrine health and current symptoms.

Best Practices
  • Personalize the AI voice to sound familiar to the practice
  • Schedule calls during mid-morning for higher pick-up rates
Common Pitfalls
  • Proceeding with the clinical interview without multi-factor identity verification
3

Glucose and Lab Data Gathering

The AI prompts the patient for recent Continuous Glucose Monitor (CGM) trends or manual finger-stick logs. For thyroid patients, the AI confirms if the scheduled TSH and T4 blood work has been completed at the lab.

Best Practices
  • Ask for the last 7 days of glucose averages
  • Verify the specific lab location used for TSH draws
Common Pitfalls
  • Accepting vague 'it's fine' answers instead of numerical data
4

Medication Adherence & Side Effect Screening

Screen for insulin adherence and hypoglycemia frequency. The AI asks specific questions about injection site rotation and any symptoms of thyroid hormone imbalance, such as fatigue, heart palpitations, or weight changes.

Best Practices
  • Ask specifically about night-time sweats or dizziness
  • Check for levothyroxine timing relative to breakfast
Common Pitfalls
  • Not asking about OTC supplements that interfere with thyroid absorption
5

Lifestyle and Nutritional Goal Tracking

Review progress on nutritional goals and physical activity. The AI records patient-reported barriers to lifestyle changes, such as cost of healthy foods or mobility issues, providing a holistic view of the patient's health.

Best Practices
  • Focus on one small dietary change per month
  • Encourage CGM use for real-time lifestyle feedback
Common Pitfalls
  • Overwhelming the patient with too many lifestyle goals at once
6

Clinical Alerting & EHR Documentation

The system generates a structured note for the EHR, capturing the time spent for APCM billing. If critical values like severe hyperglycemia are reported, the AI immediately escalates the call to a clinical staff member.

Best Practices
  • Use automated time-tracking logs for billing audit defense
  • Set specific alert thresholds for A1C and TSH deviations
Common Pitfalls
  • Failing to sign the care coordination note within 48 hours

Expected Outcomes

1

Increased monthly APCM reimbursement revenue through consistent documentation

2

Improved A1C levels via proactive glucose monitoring and adherence support

3

Reduced staff burden for routine follow-ups and data collection

4

Enhanced patient adherence to complex insulin and thyroid regimens

5

Timely thyroid medication adjustments based on automated lab tracking

Frequently Asked Questions

By automating the 20 minutes of non-face-to-face care coordination required monthly, AI ensures you never miss a billing cycle for your large diabetic and thyroid patient panels.

The AI identifies when a patient is struggling with their current regimen and flags them for a provider review. It automates data collection so the doctor can make informed titration decisions faster.

The AI is programmed with clinical red-flag triggers. If a patient reports emergency symptoms, the system immediately routes the call to your urgent triage line or advises the patient to contact emergency services.

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Endocrinology Chronic Care Monthly Check-In Workflow | Tile Health