Workflow GuideOsteoporosis

Osteoporosis Chronic Care Risk Stratification Workflow

Optimize osteoporosis outcomes with our AI-driven risk stratification workflow for DEXA scheduling, fall prevention, and APCM enrollment.

Effective osteoporosis management requires precise risk stratification to prevent debilitating fractures. This workflow guides practices through identifying high-risk Medicare patients, automating DEXA follow-ups, and managing complex medication schedules like denosumab and bisphosphonates using AI-powered call center technology to ensure no patient is missed.

The Challenge

Manual risk tracking often leads to missed DEXA scans, poor medication adherence, and unaddressed fall risks, resulting in preventable fractures and lost APCM revenue for the practice due to inconsistent documentation and patient follow-up.

Step-by-Step Workflow

1

Automated EHR Data Mining

Use AI tools to scan EHR records for ICD-10 codes related to bone density (M81.0), previous fractures, and age-related Medicare eligibility to identify the initial patient cohort for stratification.

Best Practices
  • Integrate with Z-codes for social determinants
  • Filter by last DEXA date to identify overdue patients
Common Pitfalls
  • Relying on manual chart review
  • Ignoring secondary causes of bone loss like steroid use
2

FRAX Score Calculation & Outreach

Automated outreach to collect missing clinical data needed for FRAX (Fracture Risk Assessment Tool) scores, such as family history or smoking status, via patient surveys handled by AI voice bots.

Best Practices
  • Use AI voice bots for rapid data collection
  • Sync survey results directly to the patient portal
Common Pitfalls
  • Incomplete data entry for FRAX calculation
  • Delaying outreach until the next office visit
3

Stratification into Care Tiers

Categorize patients into Low, Moderate, and High risk based on T-scores and fracture history to determine the frequency of DEXA scans and the intensity of APCM monitoring required.

Best Practices
  • High risk requires monthly touchpoints
  • Automate tier-based scheduling workflows
Common Pitfalls
  • Treating all osteopenia patients as low risk
  • Failing to update tiers after a new fall event
4

Medication Adherence & Monitoring

Implement automated reminders for denosumab (Prolia) injections and bisphosphonate refills, ensuring patients remain compliant with their specific treatment protocols and monitoring for side effects.

Best Practices
  • Set 6-month injection alerts for Prolia
  • Monitor for GI upset via AI check-in calls
Common Pitfalls
  • Missing the 6-month window for denosumab
  • Not tracking oral bisphosphonate refill frequency
5

Fall Risk & Home Safety Evaluation

Deploy AI-driven phone assessments to screen for home hazards and balance issues, triggering a physical therapy referral or home safety evaluation for high-risk individuals in the system.

Best Practices
  • Ask about recent near-miss falls
  • Include vision check reminders for elderly patients
Common Pitfalls
  • Assuming patients will self-report falls
  • Ignoring environmental factors in the home
6

DEXA Scheduling & Pre-Visit Counseling

Automatically schedule DEXA scans based on Medicare's 24-month coverage rule or clinical necessity, while providing automated prep instructions to the patient to ensure scan accuracy.

Best Practices
  • Remind patients to stop calcium 24 hours prior
  • Confirm insurance coverage automatically
Common Pitfalls
  • Scheduling DEXA scans too early for Medicare reimbursement
  • Failing to provide prep instructions
7

Secondary Fracture Prevention (SFP) Enrollment

For patients who have recently suffered a fracture, trigger an immediate high-intensity care plan focused on preventing the 'second break' through rapid pharmacological intervention.

Best Practices
  • Prioritize post-fracture patients in the care queue
  • Coordinate with orthopedic specialists for follow-up
Common Pitfalls
  • Missing the 'teachable moment' post-fracture
  • Inconsistent follow-up after hospital discharge

Expected Outcomes

1

Increased APCM enrollment for osteoporosis patients

2

Reduced secondary fracture rates through proactive monitoring

3

Improved DEXA scan compliance and scheduling accuracy

4

Higher medication adherence for denosumab and bisphosphonates

5

Enhanced documentation for Medicare quality measures

Frequently Asked Questions

AI automates the identification of high-risk patients by scanning EHR data and conducting proactive outreach, ensuring no patient falls through the cracks of manual tracking.

Denosumab requires strict 6-month dosing; automation prevents missed windows that could lead to rapid bone density loss and increased fracture risk.

AI-powered call systems use validated screening questions to identify high-risk patients, allowing staff to focus on clinical interventions rather than routine screening.

Yes, the structured monitoring and documentation provided by the AI workflow meet the requirements for Advanced Primary Care Management (APCM) reimbursement.

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Osteoporosis Chronic Care Risk Stratification Workflow | Tile Health