Internal Medicine Chronic Care Enrollment Checklist

Run EHR reports to identify patients with two or more chronic conditions such as Diabetes, HTN, or CKD.

Verify active Medicare Part B coverage and APCM risk stratification levels for each identified patient.

Filter for patients with hospitalizations or ER visits within the last 12 months to prioritize high-risk cases.

Identify patients prescribed 5 or more maintenance medications requiring intensive monthly reconciliation.

Match the target list with patients due for their Annual Wellness Visit to bundle enrollment discussions.

Deploy AI voice agents to explain the benefits of 24/7 care coordination to eligible senior patients.

Utilize AI to capture and record verbal consent for Medicare billing, ensuring HIPAA compliance.

Automatically sync AI outreach call summaries and consent status directly into the patient's chart.

Allow the AI agent to schedule the initial care plan visit if the patient agrees to participate.

Confirm the best times and methods for monthly care management check-ins during the initial call.

Compare EHR lists with patient-reported current usage to identify potential drug-drug interactions.

Define measurable health goals for each chronic condition, such as A1c targets or BP ranges.

Document specific steps for the patient to take during symptom exacerbation to avoid unnecessary ER visits.

List all active specialists (Cardiology, Nephrology, etc.) and establish a communication loop.

Assess for barriers like transportation or food insecurity that may impact chronic disease adherence.