Workflow GuideGastroenterology

GI Chronic Care Monthly Check-In Workflow & Guide

Optimize GI chronic care with our monthly check-in workflow for IBD, liver disease, and GERD. Improve APCM revenue and patient outcomes with AI automation.

Effective management of chronic GI conditions like Crohn’s, ulcerative colitis, and cirrhosis requires consistent touchpoints beyond the clinic. This workflow outlines a structured monthly check-in process designed to capture clinical changes, ensure medication adherence for biologics, and fulfill documentation requirements for Advanced Primary Care Management (APCM) and CCM billing in a GI set...

The Challenge

GI practices often lose revenue and patient engagement because manual follow-ups for chronic conditions are resource-intensive, leading to missed biologic doses, unmonitored lab trends in liver disease, and failure to meet 20-minute monthly billing thresholds for APCM.

Step-by-Step Workflow

1

Automated Eligibility Screening & Outreach

Use AI-driven call systems to identify and contact patients with IBD, cirrhosis, or chronic hepatitis who qualify for APCM based on their last procedure or visit history.

Best Practices
  • Filter by ICD-10 codes for K50.x and K51.x
  • Sync AI outreach with EHR schedules
Common Pitfalls
  • Manual calling of the entire patient list
  • Ignoring patients on long-term PPIs
2

Symptom Assessment & Flare Identification

Conduct a structured interview focusing on stool frequency, abdominal pain, and systemic symptoms like fatigue or joint pain to detect early signs of an IBD flare.

Best Practices
  • Use the Harvey-Bradshaw Index for Crohn's
  • Ask about nocturnal bowel movements
Common Pitfalls
  • Asking generic 'how are you' questions
  • Failing to document specific symptom changes
3

Medication Adherence & Biologic Review

Verify adherence to biologic schedules (e.g., Infliximab, Vedolizumab) and screen for side effects or injection site reactions that might lead to non-compliance.

Best Practices
  • Confirm the date of the next infusion or injection
  • Check for specialty pharmacy delivery issues
Common Pitfalls
  • Assuming the patient is following the schedule
  • Not documenting the specific biologic lot or date
4

Lab Work & Diagnostic Monitoring

Review recent LFTs, fecal calprotectin, or therapeutic drug monitoring results and ensure the patient has scheduled upcoming required bloodwork for liver or IBD monitoring.

Best Practices
  • Automate reminders for overdue lab orders
  • Discuss the importance of calprotectin levels with the patient
Common Pitfalls
  • Proceeding without reviewing the most recent labs
  • Failing to order labs before the next check-in
5

Nutritional & Lifestyle Assessment

Evaluate dietary triggers, weight changes, and hydration levels, especially for patients with short bowel syndrome, celiac disease, or advanced cirrhosis.

Best Practices
  • Ask about unintentional weight loss
  • Provide digital resources for low-FODMAP or Mediterranean diets
Common Pitfalls
  • Overlooking the impact of diet on GI symptoms
  • Ignoring rapid weight changes in cirrhosis patients
6

APCM Documentation & Care Plan Update

Log the interaction time and update the patient's comprehensive care plan in the EHR to reflect new symptoms, medication changes, or updated goals for the coming month.

Best Practices
  • Ensure at least 20 minutes of non-face-to-face time is recorded
  • Explicitly state changes to the care plan
Common Pitfalls
  • Vague documentation that doesn't meet CMS requirements
  • Forgetting to update the 'last reviewed' date on the care plan

Expected Outcomes

1

Increased enrollment in APCM programs for IBD and liver disease patients.

2

Reduction in emergency room visits due to early detection of flares.

3

Higher adherence rates for biologic therapies and specialty medications.

4

Improved documentation accuracy for GI-specific chronic care billing.

5

Enhanced patient satisfaction through consistent, proactive communication.

Frequently Asked Questions

AI call handling automates the initial outreach and data collection, ensuring no patient is missed while freeing up clinical staff for complex triage and procedure preparation.

Yes, monthly check-ins are essential for GERD patients on long-term PPIs to monitor for side effects like bone density issues or hypomagnesemia and to assess the possibility of step-down therapy.

Requirements include at least 20 minutes of clinical staff time per month, a certified EHR, a comprehensive care plan, and 24/7 access to care for patients with two or more chronic conditions.

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GI Chronic Care Monthly Check-In Workflow & Guide | Tile Health