Workflow GuideInfectious Disease

ID Chronic Care Risk Stratification & APCM Workflow Guide

Optimize Infectious Disease patient outcomes with this chronic care risk stratification workflow for HIV, Hep B, and Long COVID management.

Effective risk stratification in Infectious Disease practices is essential for managing complex cases like HIV, Hepatitis B, and Long COVID. By categorizing patients based on clinical stability, medication adherence, and social determinants of health, practices can deploy AI-driven outreach to ensure high-risk patients receive the intensive monitoring required for APCM compliance and viral supp...

The Challenge

ID practices struggle to identify which patients require proactive outreach versus routine follow-ups, often leading to missed viral load checks, poor ART adherence, and lost revenue from CMS's new Infection-Associated Chronic Condition (IACCI) billing codes.

Step-by-Step Workflow

1

Identify IACCI-Eligible Patient Population

Filter your EHR for patients with HIV/AIDS, chronic Hepatitis B, or Long COVID conditions lasting more than three months. These patients qualify for the new Infection-Associated Chronic Condition Illnesses (IACCI) reimbursement model.

Best Practices
  • Use specific ICD-10 codes for chronic infections to automate the list generation.
Common Pitfalls
  • Overlooking Long COVID patients who may not yet be coded for chronic care management.
2

Assess Clinical Stability and Viral Load Trends

Review the last 12 months of lab data. Categorize patients based on CD4 counts, viral suppression status, and frequency of opportunistic infections to determine clinical risk levels.

Best Practices
  • Prioritize patients with detectable viral loads for immediate outreach.
Common Pitfalls
  • Failing to update risk scores after a patient achieves viral suppression.
3

Evaluate Medication Adherence and Pharmacy Data

Analyze prescription refill patterns for antiretroviral therapy (ART) or HBV antivirals. Use AI call history to identify patients who frequently call with concerns about side effects or refill delays.

Best Practices
  • Integrate pharmacy fill data directly into the risk assessment tool.
Common Pitfalls
  • Assuming a patient is adherent just because they haven't called the office.
4

Analyze Social Determinants of Health (SDOH)

Infectious disease outcomes are heavily influenced by housing, transportation, and food security. Assign higher risk scores to patients in vulnerable populations who may require Ryan White Program assistance.

Best Practices
  • Use standardized SDOH screening tools during intake calls.
Common Pitfalls
  • Ignoring non-clinical barriers that lead to missed appointments.
5

Assign Risk Tiers for APCM Enrollment

Categorize patients into Tier 1 (Stable/Suppressed), Tier 2 (At-Risk/Intermittent Adherence), and Tier 3 (Critical/Unstable). This determines the frequency of AI-powered check-ins and nurse interventions.

Best Practices
  • Ensure Tier 3 patients have a dedicated case manager assigned.
Common Pitfalls
  • Applying a one-size-fits-all outreach strategy to all HIV patients.
6

Implement AI-Driven Outreach Protocols

Deploy Tile Healthcare AI to handle routine adherence check-ins for Tier 1 and 2 patients. The AI can screen for new symptoms or barriers and escalate high-risk responses to clinical staff immediately.

Best Practices
  • Configure the AI to ask specific questions about common ART side effects.
Common Pitfalls
  • Manual calling for all patients, which leads to staff burnout and missed contacts.
7

Continuous Monitoring and APCM Documentation

Log all AI interactions and clinical touches in the EHR to meet CMS APCM documentation requirements. Re-stratify patients every 90 days based on new lab results and adherence data.

Best Practices
  • Use automated reporting to track the time spent on non-face-to-face care.
Common Pitfalls
  • Losing billing revenue due to insufficient documentation of monthly care management.

Expected Outcomes

1

Increased viral suppression rates across the HIV and Hep B patient populations.

2

Higher capture rate of APCM and IACCI-related billing revenue.

3

Reduced administrative burden on ID nursing staff through AI automation.

4

Improved patient retention in care, particularly for vulnerable populations.

5

Enhanced compliance with Ryan White Program reporting and quality metrics.

Frequently Asked Questions

IACCI stands for Infection-Associated Chronic Condition Illnesses. CMS now recognizes certain chronic infections, like HIV and Hepatitis, as qualifying conditions for Chronic Care Management (CCM) and Advanced Primary Care Management (APCM) billing.

AI call solutions provide consistent, non-judgmental check-ins that remind patients of their ART schedule, identify barriers to pharmacy access, and capture side effect data that might otherwise go unreported.

Yes. Long COVID patients often require complex, multi-symptom management over many months. Risk stratifying these patients allows ID practices to provide the structured monitoring required for APCM reimbursement.

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ID Chronic Care Risk Stratification & APCM Workflow Guide | Tile Health