Workflow GuideOsteoporosis

Osteoporosis Chronic Care Monthly Check-In Workflow

Optimize Osteoporosis chronic care management with our monthly check-in workflow. Improve DEXA scheduling, fall risk assessments, and APCM compliance.

Managing osteoporosis in a Medicare population requires consistent monthly touchpoints to ensure medication adherence, fall prevention, and timely DEXA scans. This workflow streamlines the chronic care monthly check-in process, leveraging AI-driven communication to capture critical bone health data and improve patient outcomes while meeting APCM documentation standards.

The Challenge

Manual outreach for osteoporosis patients is often inconsistent, leading to missed denosumab doses, overlooked fall risks, and gaps in DEXA monitoring. Practices struggle to maintain the high-frequency contact required for APCM reimbursement and effective secondary fracture prevention.

Step-by-Step Workflow

1

Automated Pre-Call Screening

Use AI to identify patients due for their monthly check-in based on their last denosumab injection or DEXA scan date. The system initiates a secure call or text to confirm the patient's current mobility status and any recent falls or fractures.

Best Practices
  • Integrate with EHR for real-time scheduling data
  • Segment patients by fracture risk score
Common Pitfalls
  • Calling patients manually without checking recent scan results
2

Medication Adherence & Side Effect Review

Verify adherence to oral bisphosphonates or schedule the next denosumab injection. The AI assistant asks about gastrointestinal issues or new bone pain, flagging potential side effects for clinical review.

Best Practices
  • Ask specifically about morning dosing routines for oral meds
  • Document the date of the next injection clearly
Common Pitfalls
  • Ignoring minor GI complaints that lead to non-compliance
3

Fall Risk & Home Safety Assessment

Conduct a structured fall risk assessment by asking about recent near-misses, lighting at home, and the use of assistive devices. AI tools can score these responses to prioritize high-risk patients for a physical therapy referral.

Best Practices
  • Include questions about vision changes and footwear
  • Provide immediate home safety tips during the call
Common Pitfalls
  • Waiting for a fracture to occur before assessing fall risk
4

Supplement & Lifestyle Counseling

Review daily intake of Calcium and Vitamin D3 while reinforcing the importance of weight-bearing exercises. The AI provides personalized educational snippets based on the patient's current activity level and dietary habits.

Best Practices
  • Reference NOF daily intake guidelines
  • Encourage silver sneakers or local walking groups
Common Pitfalls
  • Overlooking the role of Vitamin D in bone mineralization
5

DEXA Scan Coordination

Check the status of the biennial DEXA scan and facilitate immediate scheduling if the patient is eligible. The system explains the importance of bone density monitoring to ensure patient buy-in for the appointment.

Best Practices
  • Verify Medicare coverage intervals before calling
  • Send automated reminders for the DEXA appointment
Common Pitfalls
  • Failing to follow up on overdue scans for high-risk patients
6

APCM Documentation & Care Plan Update

Automatically log the interaction duration and key clinical findings into the EHR to satisfy Medicare APCM requirements. The AI generates a summary of the call, highlighting any changes in the patient's fracture risk or mobility.

Best Practices
  • Ensure call logs capture 'clinical staff time' correctly
  • Update the care plan with the latest fall risk score
Common Pitfalls
  • Incomplete documentation that leads to reimbursement denials

Expected Outcomes

1

Increased adherence to denosumab and bisphosphonate therapy protocols.

2

Improved DEXA scan compliance through proactive scheduling and reminders.

3

Reduction in preventable falls through monthly home safety assessments.

4

Streamlined APCM documentation and increased practice revenue.

5

Enhanced patient education regarding bone-healthy lifestyle modifications.

Frequently Asked Questions

AI automates the repetitive monthly outreach, ensuring no patient is missed and capturing standardized fall risk data that is often overlooked in busy clinics.

Yes, by documenting consistent monthly clinical interactions and monitoring medication adherence, this workflow provides the necessary data to support APCM billing.

The AI system immediately flags the response and alerts a clinical team member for urgent follow-up and potential referral to physical therapy.

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Osteoporosis Chronic Care Monthly Check-In Workflow | Tile Health