Workflow GuideOB/GYN & Women's Health

OB/GYN Chronic Care Monthly Check-In Workflow

Streamline OB/GYN & Women's Health chronic care with AI-driven monthly check-ins for HRT, osteoporosis, and pelvic pain management.

For many Medicare-age women, their gynecologist serves as their de facto primary care provider. Managing chronic conditions like osteoporosis, hormone replacement therapy (HRT), and pelvic floor disorders requires consistent monthly monitoring that often overwhelms traditional staff. This workflow leverages AI-powered automation to ensure no patient falls through the cracks while capturing APCM...

The Challenge

OB/GYN practices often focus on high-volume obstetric revenue, leaving GYN-only Medicare patients with chronic conditions underserved. Manual monthly check-ins for HRT side effects or bone density progress are time-consuming, leading to lost billing opportunities and fragmented care.

Step-by-Step Workflow

1

Identify Eligible Medicare/APCM Patients

Filter your EHR for GYN patients with two or more chronic conditions, such as osteoporosis and hypertension, or those requiring long-term hormone replacement therapy monitoring.

Best Practices
  • Use ICD-10 codes for postmenopausal osteoporosis (M81.0) to find candidates
  • Focus on patients who have transitioned from OB to GYN-only care
Common Pitfalls
  • Excluding patients with well-managed chronic conditions who still qualify for APCM
2

Deploy AI-Powered Outreach

Utilize AI call handling to initiate monthly check-ins. The AI can ask structured questions about medication adherence and new symptoms, reducing manual phone tag.

Best Practices
  • Schedule calls for mid-morning when Medicare patients are most reachable
  • Ensure the AI voice is empathetic and tailored to women's health concerns
Common Pitfalls
  • Using generic robocalls that patients often ignore
3

Screen for HRT and Bone Health Symptoms

The AI screens for vasomotor symptoms, breakthrough bleeding, or bone pain. It also assesses for side effects related to bisphosphonates or HRT patches.

Best Practices
  • Include specific questions about localized pelvic pain or urinary changes
  • Ask about compliance with Vitamin D and Calcium supplementation
Common Pitfalls
  • Failing to document the absence of symptoms for negative-finding records
4

Perform Medication Reconciliation

Confirm the patient is taking their prescribed hormones or osteoporosis medications. Identify pharmacy barriers or cost issues that lead to non-compliance.

Best Practices
  • Ask if they have enough refills remaining for the next 30 days
  • Verify the use of any new OTC supplements that may interfere with GYN meds
Common Pitfalls
  • Assuming a patient is compliant just because a script was sent
5

Document and Bill for APCM/CCM

The AI logs the interaction time and patient responses directly into the EHR. This documentation supports Medicare billing for chronic care management services.

Best Practices
  • Ensure the log shows at least 20 minutes of clinical staff time per month
  • Use a dedicated APCM template for consistent GYN-specific documentation
Common Pitfalls
  • Losing revenue by failing to capture time spent on non-face-to-face care coordination
6

Clinical Escalation for Red Flags

Any reports of postmenopausal bleeding, severe pelvic pain, or new breast lumps trigger an immediate transfer to a triage nurse or provider.

Best Practices
  • Set clear parameters for what constitutes an 'immediate' clinical concern
  • Automatically book follow-up imaging for patients reporting new pain
Common Pitfalls
  • Delaying escalation for high-risk symptoms like postmenopausal bleeding

Expected Outcomes

1

Increased monthly recurring revenue through APCM and CCM billing

2

Improved patient adherence to HRT and osteoporosis treatment plans

3

Reduced administrative burden on front-desk and nursing staff

4

Higher patient satisfaction among the Medicare GYN population

5

Early detection of complications in gynecologic cancer survivors

Frequently Asked Questions

Yes, as long as the OB/GYN is the provider managing the specific chronic conditions listed in the care plan, such as chronic pelvic pain or osteoporosis.

The AI is programmed with specific logic to identify 'red flag' symptoms; if a patient describes complex issues, the system immediately routes the call to a clinical staff member.

You must have a documented care plan, patient consent for chronic care services, and a log of at least 20 minutes of non-face-to-face clinical time per month.

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OB/GYN Chronic Care Monthly Check-In Workflow | Tile Health