Workflow GuidePulmonology

Pulmonology Chronic Care Monthly Check-In Workflow

Optimize COPD and asthma management with our pulmonology monthly check-in workflow. Reduce readmissions and improve APCM compliance using AI automation.

Managing chronic respiratory conditions like COPD and ILD requires consistent touchpoints to prevent exacerbations. This workflow leverages AI-powered automation to conduct monthly check-ins, ensuring medication adherence, monitoring symptom changes, and tracking pulmonary rehab progress without overwhelming clinical staff or respiratory therapists.

The Challenge

Manual outreach for hundreds of chronic respiratory patients is labor-intensive, leading to missed exacerbation signs, poor inhaler technique adherence, and high hospital readmission rates that negatively impact APCM performance and patient outcomes.

Step-by-Step Workflow

1

Automated Outreach Trigger

The AI system initiates calls to COPD, asthma, and ILD patients enrolled in chronic care programs based on their individual APCM billing cycle or clinical needs.

Best Practices
  • Schedule calls during mid-morning when patients are most alert
  • Sync with EMR to ensure correct patient contact data
Common Pitfalls
  • Failing to update contact info after hospital discharge
2

Standardized Symptom Screening

AI uses GOLD guideline-based questions to identify increased dyspnea, changes in sputum color/volume, or spikes in rescue inhaler usage over the last 30 days.

Best Practices
  • Use the mMRC Dyspnea Scale in the conversation flow
  • Ask specifically about nocturnal awakenings for asthma patients
Common Pitfalls
  • Accepting vague 'I feel fine' answers without probing for specific changes
3

Medication & Inhaler Review

The system verifies adherence to maintenance inhalers and confirms the patient has an adequate supply of rescue medications and spacers.

Best Practices
  • Ask the patient to read the dose counter on their inhaler
  • Confirm if they are using their spacer with every MDI dose
Common Pitfalls
  • Assuming patients know the difference between controller and rescue meds
4

Oxygen & DME Equipment Check

For patients on home oxygen or CPAP, the AI confirms flow rates match current prescriptions and checks for any equipment malfunctions or supply needs like filters.

Best Practices
  • Verify the hours of usage for CPAP/BIPAP compliance
  • Remind patients to check their backup oxygen tank levels
Common Pitfalls
  • Overlooking the need for replacement nasal cannulas or tubing
5

Pulmonary Rehab & Activity Tracking

AI documents recent physical activity levels or progress in pulmonary rehabilitation, encouraging patients to maintain their exercise prescriptions.

Best Practices
  • Congratulate patients on completing rehab milestones
  • Ask about barriers to attending scheduled rehab sessions
Common Pitfalls
  • Neglecting the psychological impact of social isolation on COPD patients
6

Smoking Cessation & Environmental Screening

AI screens for tobacco use or exposure to environmental triggers like wildfire smoke, high pollen counts, or indoor pollutants.

Best Practices
  • Provide immediate referrals to smoking cessation hotlines if interest is expressed
  • Advise on air quality alerts during high-risk seasons
Common Pitfalls
  • Being judgmental about smoking status which discourages honest reporting
7

Clinical Escalation for Red Flags

If the AI detects symptoms of an acute exacerbation, it immediately routes the call to a live respiratory therapist or nurse for triage.

Best Practices
  • Set clear parameters for what constitutes a 'red flag' event
  • Ensure the triage nurse has the call transcript in real-time
Common Pitfalls
  • Delaying escalation for patients reporting severe shortness of breath
8

EMR Documentation & APCM Billing

The AI syncs the structured data and call transcript directly to the EMR, automatically documenting the time spent to support APCM and CCM billing codes.

Best Practices
  • Use standardized templates for easy billing audits
  • Ensure the provider reviews and signs off on the AI-generated note
Common Pitfalls
  • Failing to document the specific duration of the clinical interaction

Expected Outcomes

1

Significant reduction in 30-day hospital readmission rates for COPD

2

Improved adherence to GOLD and GINA treatment protocols

3

Increased capture of billable APCM minutes through automated tracking

4

Enhanced patient safety through early detection of respiratory distress

5

Reduced administrative burden on respiratory therapists and clinic staff

Frequently Asked Questions

The AI uses natural language processing to recognize specific keywords and patterns related to exacerbations, immediately flagging high-risk responses for human clinical intervention.

Yes, by identifying early signs of worsening COPD or pneumonia, the system allows for outpatient adjustments that prevent costly emergency visits and hospitalizations.

Absolutely. All interactions are encrypted, and data integration with your EMR follows strict HIPAA and HITRUST security standards to protect sensitive respiratory health data.

While the AI cannot see the patient, it asks specific procedural questions about the steps of inhaler use to identify knowledge gaps that require a video or in-person follow-up.

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Pulmonology Chronic Care Monthly Check-In Workflow | Tile Health