Endocrinology Chronic Care Patient Enrollment Checklist

Screen your EHR for patients with an A1C consistently over 8.0% or a history of recurrent hypoglycemia.

Cross-reference diabetes patients with secondary diagnoses such as hypertension, obesity, or CKD to meet APCM requirements.

Flag patients on levothyroxine or methimazole who require quarterly TSH monitoring and dosage adjustments.

Confirm Medicare or private payer eligibility for CCM (99490) or APCM billing codes prior to outreach.

Identify patients utilizing continuous glucose monitors who require frequent data review and technical support.

Use automated AI voice systems to call eligible patients and explain the benefits of chronic care monitoring.

Allow the AI agent to book the initial care plan consultation directly into the practice management software.

Set up automated SMS or email reminders for patients who did not answer the initial enrollment phone call.

Ensure AI outreach is conducted in the patient's primary language to improve enrollment rates in diverse populations.

Review AI dashboards to monitor conversion rates from initial call to successful program enrollment.

Obtain and log verbal or electronic consent for chronic care services, ensuring it is documented in the EHR.

Develop a comprehensive care plan including A1C targets, insulin titration protocols, and weight management goals.

Configure AI call handling to provide patients with 24/7 access to the care team for urgent endocrine concerns.

Perform a full review of endocrine medications and potential interactions with treatments for comorbidities.

Initialize a system to track the 20 minutes of non-face-to-face care required monthly for billing compliance.