Neurology Chronic Care & APCM Patient Enrollment Checklist

Verify the patient has two or more chronic conditions, such as Epilepsy and Migraine, expected to last 12+ months for CCM billing.

Flag patients with a single high-risk condition like Alzheimer's or Parkinson's for Principal Care Management (APCM) eligibility.

Record all current DMTs for MS or titration schedules for Parkinson's to establish the baseline for monthly monitoring.

Input the most recent MoCA or MMSE scores to determine the necessary level of caregiver involvement in the care plan.

Note any stroke-related hospitalizations or seizure-related ER visits within the last 30 days to prioritize high-risk outreach.

Document the legal healthcare proxy or family member responsible for medication administration and symptom reporting.

Use AI call recording to capture and timestamp verbal consent from the patient or proxy for monthly care services.

Determine if the caregiver prefers SMS, phone calls, or portal messaging for submitting seizure logs or motor fluctuation reports.

Confirm the contact information for specialty pharmacies handling complex infusions or Parkinson's rescue medications.

Document specific caregiver steps for cluster seizures or sudden 'off' periods to be included in the digital care plan.

Define measurable targets, such as reducing migraine frequency or improving gait stability, for the AI to track during check-ins.

Configure AI call workflows to prompt patients about anti-epileptic drug (AED) adherence at intervals defined by the neurologist.

Set automated outreach to identify transportation or financial barriers for MS patients requiring regular in-clinic infusions.

Incorporate recent fall history into the care plan to trigger automated physical therapy referrals if symptoms worsen.

Ensure all AI-captured enrollment data and consent records are automatically pushed to the neurology EHR for audit readiness.