Workflow GuideHypertension Management

Hypertension Risk Stratification Workflow for Chronic Care Management

Optimize Hypertension Management with our risk stratification workflow. Improve APCM enrollment, BP monitoring, and medication adherence for Medicare patients.

Effective hypertension management requires a systematic approach to risk stratification to identify high-risk Medicare patients prone to stroke or kidney failure. This workflow leverages AI-driven call handling to automate patient outreach, capture home blood pressure data, and categorize patients based on AHA/ACC guidelines for personalized chronic care interventions.

The Challenge

Manual risk stratification for thousands of hypertensive patients is labor-intensive, leading to missed APCM enrollment opportunities and delayed medication titration for those with resistant hypertension or poor adherence.

Step-by-Step Workflow

1

Initial Population Screening

Identify all Medicare patients with ICD-10 codes for hypertension (I10, I15) and cross-reference with recent BP readings to define the APCM-eligible pool.

Best Practices
  • Use EMR filters to find patients with BP > 140/90 in the last 6 months
Common Pitfalls
  • Excluding patients with 'white coat hypertension' who still need monitoring
2

AI-Driven Baseline Outreach

Deploy automated call handling to collect recent home BP readings and assess medication adherence using standardized questionnaires without manual staff effort.

Best Practices
  • Schedule calls at times when patients are likely home to take readings
Common Pitfalls
  • Using overly technical medical jargon in automated voice prompts
3

Comorbidity Mapping and Stratification

Stratify patients by identifying co-occurring conditions like CKD, diabetes, or heart failure that increase the risk of hypertensive emergencies.

Best Practices
  • Prioritize patients with renal artery stenosis for frequent monitoring
Common Pitfalls
  • Treating hypertension as an isolated condition in multi-morbid patients
4

BP Control Classification

Categorize patients into controlled, Stage 1, Stage 2, or Hypertensive Crisis levels based on longitudinal data trends captured via AI interactions.

Best Practices
  • Look for trends rather than single isolated high readings
Common Pitfalls
  • Ignoring low BP readings which may indicate over-medication
5

Medication Adherence Scoring

Use AI call logs to identify patients struggling with side effects or forgetfulness, flagging them for immediate pharmacist or clinician review.

Best Practices
  • Ask specific questions about common side effects like edema or cough
Common Pitfalls
  • Assuming a filled prescription equals a consumed dose
6

RPM Integration and Onboarding

Identify patients suitable for Remote Patient Monitoring (RPM) and automate the onboarding process for cellular-connected BP cuffs.

Best Practices
  • Focus RPM enrollment on patients with resistant hypertension
Common Pitfalls
  • Failing to document the medical necessity of the RPM device
7

Prioritized Clinical Intervention

Generate daily task lists for the care team, focusing on patients with 'Resistant Hypertension' or those requiring titration based on high average readings.

Best Practices
  • Use AI to filter out noise so staff only see actionable data
Common Pitfalls
  • Allowing high-risk alerts to get lost in a general inbox

Expected Outcomes

1

Increased APCM enrollment rates for hypertensive Medicare populations

2

Reduced incidence of hypertensive emergencies through proactive monitoring

3

Improved MIPS quality scores for blood pressure control

4

Streamlined medication titration workflows via automated data collection

5

Enhanced patient engagement and adherence through consistent AI touchpoints

Frequently Asked Questions

AI automates the collection of home BP readings and adherence data, allowing clinicians to focus on high-risk patients instead of manual data entry.

Markers include BP consistently >140/90, co-morbid CKD or diabetes, history of non-adherence, and lack of home monitoring equipment.

Yes, by documenting every automated interaction and data point, you create a robust audit trail for APCM and RPM billing requirements.

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Hypertension Risk Stratification Workflow for Chronic Care Management | Tile Health