Workflow GuideMulti-Site Practices

Chronic Care Risk Stratification for Multi-Site Practices

Standardize chronic care risk stratification across multi-site practices using AI automation to improve APCM workflows and centralized reporting.

Managing chronic care patient risk stratification across 20+ locations requires more than clinical judgment; it demands a standardized, AI-driven approach to ensure every site identifies high-risk APCM candidates consistently. This guide outlines how to unify data from disparate EHRs and automate patient outreach to stabilize your population health strategy.

The Challenge

Multi-site practices often struggle with fragmented risk stratification, where acquired sites use different criteria, leading to missed APCM revenue and inconsistent patient outcomes due to non-standardized EHR data and manual outreach bottlenecks.

Step-by-Step Workflow

1

Centralize EHR Data Aggregation

Integrate disparate EHR systems from all sites into a unified data lake to normalize patient records, chronic condition codes, and recent encounter history for global risk analysis.

Best Practices
  • Map ICD-10 codes across different EHR platforms
  • Ensure NPI-to-site mapping is accurate
Common Pitfalls
  • Ignoring data silos in newly acquired practices
2

Define Standardized Risk Tiers

Establish practice-wide criteria for High, Moderate, and Low risk based on HCC scores, number of comorbidities, and social determinants of health (SDOH) to ensure uniform APCM enrollment.

Best Practices
  • Use CMS-HCC risk adjustment models
  • Incorporate SDOH for better predictive accuracy
Common Pitfalls
  • Allowing individual sites to set their own risk thresholds
3

Deploy AI-Powered Outreach for Screening

Use AI call handling to automatically contact patients identified as potentially high-risk to verify current symptoms, medication adherence, and social needs without burdening local front-desk staff.

Best Practices
  • Configure AI to handle multi-language outreach
  • Sync call outcomes directly back to the centralized dashboard
Common Pitfalls
  • Overloading local clinic staff with manual screening calls
4

Execute Provider Attribution and Credentialing Check

Verify that each stratified patient is correctly attributed to a provider with active credentials and a valid NPI at the specific location to ensure APCM billing compliance.

Best Practices
  • Automate credentialing status checks
  • Validate site-specific Medicare enrollment
Common Pitfalls
  • Attributing patients to providers not credentialed at that specific site
5

Centralize Enrollment via Automated Scheduling

Direct patients identified as high-risk through AI screening into a centralized scheduling queue for their initial APCM assessment, bypassing site-level scheduling bottlenecks.

Best Practices
  • Use real-time calendar sync across all locations
  • Provide clear APCM benefits during the AI call
Common Pitfalls
  • Failing to follow up immediately after risk identification
6

Monitor Site-Level Performance Dashboards

Implement a centralized dashboard to track risk stratification accuracy, enrollment rates, and revenue performance across all 5-50+ locations in real-time.

Best Practices
  • Filter data by region and practice manager
  • Set alerts for sites falling below enrollment targets
Common Pitfalls
  • Relying on monthly manual reports from site managers

Expected Outcomes

1

Standardized risk identification across all 50+ locations

2

Increased APCM enrollment through automated AI outreach

3

Reduction in administrative burden for site-level staff

4

Full compliance with multi-site billing and NPI attribution

5

Centralized visibility into population health and revenue metrics

Frequently Asked Questions

Our AI-powered solution integrates with multiple EHR platforms, normalizing data into a single dashboard for centralized risk stratification and reporting.

Yes, the system verifies provider NPI and site-specific credentials during the stratification process to ensure every APCM claim is compliant.

No, the workflow centralizes the outreach and stratification process, allowing local staff to focus on clinical care while the AI manages the administrative heavy lifting.

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Chronic Care Risk Stratification for Multi-Site Practices | Tile Health