A1C is one of the most important measures in diabetes care, but it's also retrospective. 

It tells the care team what has been happening over time. It helps reveal whether glycemic control is improving, worsening, or holding steady. It gives endocrinologists a critical view of the patient’s recent history. 

But, as your providers well know, history is not the same as visibility. 

By the time an A1C rises, the story behind it may have been unfolding for weeks. Any number of scenarios have time to unfold for any number of patients. 

• One patient stopped their insulin resistance medication because it was messing with their stomach.
• Another can’t afford the prescription.
• Another had to start taking steroids after a reaction.
• Another is having issues with random seeming fluctuations in the middle of the night.
• Another had a personal event that threw their routine completely off the rails.  

Eventually, hopefully, the lab's result summarizes the outcome, but the opportunity to intervene may have existed much earlier. 

That is the central challenge facing modern endocrinology. 

The specialty has become exceptionally good at generating data in the last decade, but clinical capacity has gotten worse. Can any office in your organization truly stay up to date with patients once the appointment passes? 

Probably not.  

That is where longitudinal care models such as Chronic Care Management, connected physiological monitoring, and, where appropriate, Advanced Primary Care Management deserve serious consideration. 

Endocrinology does not need another technology layer. It needs a better way to see forward. 

Table of Contents: 

• False: Endocrinologists cannot see enough
• A1C can tell you something happened
• Poorly managed or misunderstood diabetes doesn’t wait
• CCM creates continuity where episodic cannot
• Biometric devices turn care management from retrospective to responsive
• More Visibility is Useful... If Someone Owns the Response
• Remote Care Works Best When Tech is Surrounded by Care
• APCM May Help, But it’s Not for Every Endocrinology Practice
• The Most Important Moment... Before the A1C Changes
• Endocrinology Needs a Windshield, Not Just a Rearview Mirror
• Frequently Asked Questions 

False: Endocrinologists Cannot See Enough 

Today, diabetes care can produce more information and measurements than ever before.  

For example, CGMs generate continuous trends, connected blood pressure cuffs and scales can provide additional context, patient portals can display communications to and from the patient/providers; pharmacies can send refill requests.  

Not to mention, EHRs can hold an incredible amount of content. 

• Medication lists
• Lab results
• Diagnoses
• Notes
• Encounter histories 

Specialists receive more information from more sources than previous generations of clinicians could have ever imagined. 

And so, the issue today isn’t data or the provider’s access; it lies in what happens next. What is coming next? 

• Whose role is to notice that a trend has changed for the patient?
• Who determines whether it matters?
• Who contacts the patient if it does matter?
• Who discovers that the issue is not clinical instability at all, but confusion about how to take a medication?
• Who documents the interaction?
• Who follows up?
• Who escalates to the endocrinologist? 

And who makes sure the patient does not seemingly disappear into a vacuum until the next appointment? 

Without a clear operating model—that is not the actual provider, more data can simply create more work. As helpful as it may seem, your endocrinology team does not need another dashboard that quietly adds responsibility. 

It needs a system that helps convert signals into action. 

A1C Can Tell You that Something Happened.  

But it cannot always tell you why, and, here, that distinction really matters. 

Walk with me: Suppose two patients both arrive at their next visit with a higher A1C. On paper, the problem may look similar. In reality, the causes could be completely different. 

Patient A: Higher A1C	Patient B: Higher A1C
Stopped taking meds because of money	Misunderstood dosage change
Food access caused large swings in diet	Started a steroid
Missing insulin doses	Poorly timed bolus
Struggling with depression, halting care plan engagement	Sees blood sugar changes, but doesn’t feel poorly

The A1C tells the endocrinologist that glycemic control worsened, but it doesn’t explain why. 

That requires context, conversation, and tracking information. And without between-visit program, the next appointment is the only chance to get that context. This is where chronic care management (CCM) becomes especially relevant. 

A strong CCM program does not simply ask whether the patient is “doing okay.” It builds a longitudinal relationship around the realities that affect chronic disease management. 

Such realities include: 

• Medication adherence
• Understanding of the treatment plan
• Access to prescriptions
• Recent hospital or emergency department visits
• New symptoms
• Barriers to care
• Care coordination (or lack thereof)
• Changes in other chronic conditions 

All the questions the patient did not think were important enough to bring to the specialist? Those conversations can surface problems much earlier. For diabetes care, that matters because the difference between a worsening outcome and a manageable intervention is often timing. 

Poorly Managed or Purely Misunderstood Diabetes Does Not Wait 

The traditional appointment remains essential. There is no denying that. Even so, it represents only a small fraction of the patient’s life with diabetes. 

The disease continues every day—every moment after the patient leaves the endocrinology office. They have to keep taking meds, keep eating, keep managing their blood sugar no matter what happens in the pharmacy, with their insurance, and in their homes.  

That’s not to mention any other conditions they have. 

And like all of us, our patients forget. They misunderstand. They are forced to adapt, even when that adaptation goes against their care plan. 

Diabetes management (and mismanagement) happens in all of those moments. The next endocrinology visit is likely months away. 

So, we have a problem. A continuous disease is still often managed through intermittent encounters. 

And we have a solution. Longitudinal care is one way to close that gap. 

CCM Creates Continuity Where Episodic Care Cannot 

Chronic care management is particularly relevant to endocrinology because many diabetes patients are not managing just diabetes alone. 

They may also have 

• Hypertension
• Chronic kidney disease
• Cardiovascular disease
• Obesity
• Neuropathy
• Medication complexity
• Mobility limitations
• Behavioral or mental health concerns 

This is not to mention financial barriers or social circumstances that directly affect adherence to the provider’s care plan. 

The patient experiences all of those things at once, and they never stop. And all the while—for a singular patient—the healthcare system often separates them into different visits, specialists, and workflows. 

Thankfully, services like CCM can create continuity across those gaps. 

It’s More Than a Call 

“I usually tell my first-time CCM patients that I will call and check on you monthly, but the beauty of the program is you can call me whenever you may need to.  

If you have any questions, medical concerns or really don't know what to do, call me, we will talk it through and figure it out.  

I also tell them that when you call me, you get the Registered Nurse, right away.  

I can communicate directly with your Provider, on your behalf.  

Patients really like that they don't have to go through a long menu and talk to different people, usually having to explain their problem from the beginning.  

When they talk to me, I already know them and everything they've been through.” 

- CCM Nurse G.K. 

The value is not simply that someone calls the patient, ticking off a box. The value is that someone with the proper training and tools maintains awareness of the patient over time. 

For the patient, that can mean more support. For the endocrinologist, it can mean better, medically filtered information. And for the practice, it can mean fewer situations in which the specialist has to discover months of unresolved problems during a single visit. 

Connected Biometric Devices, Turn Care Management From Retrospective to Responsive 

CCM becomes even more powerful when it is paired with objective physiological information. Traditional care management relies heavily on memory—of your patients and your providers. Picture the conversations you have during a typical visit. 

“How have your readings been?” 

“Has anything been different?” 

“Any complaints?” 

Those are reasonable questions. They are also all the provider has time for. 

Be that as it may, they depend on the patient noticing the change, remembering it, understanding its importance, and communicating it accurately. 

Now, consider the visit with a stack of reading data recorded in the comfort of their own home. 

Instead of: “How have things been?” 

The conversation can begin with: “Your readings have been trending higher this week. Did anything change?” 

That shift is small in wording and significant in practice. As we like to say, the device provides the signal and the care-management relationship provides the context. 

Together, they can create a more useful (and accurate) picture. 

More Visibility is Useful... If Someone Owns the Response 

Remote care strategies fall apart right here. There is such an emphasis on collection that they forget about the operational reality waiting for the moment information is collected.  

To demonstrate, consider who owns a new stream of data. Who owns it? If no one is clearly responsible, the practice is just creating another inbox. That is not innovation. It’s a workload transfer. 

The strongest remote-care models answer operational questions before adding technology. 

• Who monitors incoming information?
• Who engages the patient?
• Who handles routine education?
• Who addresses adherence problems?
• Who identifies barriers?
• What does escalation require and what does not?
• How quickly should the team respond?
• How is the interaction documented?
• How does the endocrinologist stay informed without becoming the first point of contact for every issue? 

In our experience, remote care only works when someone owns the space between signal and action. The endocrinologist should not and cannot be the operating system for the entire program, but that is often the position they’re stuck in.  

Endocrinology already faces significant capacity pressure and as diabetes prevalence rises and patients become more complex, the answer cannot be to route every new responsibility back to the specialist. 

All that does is scale the specialist’s burden. A better model, one we prefer, protects endocrinology expertise. It looks like this: 

• Routine outreach can be handled by an appropriate clinical team.
• Adherence issues can be investigated.
• Barriers can be identified.
• Care coordination can happen.
• Data can be reviewed and filtered.
• Patterns can be contextualized. 

Then, and only then, the endocrinologist becomes involved when the decision truly requires endocrinology expertise. 

The goal of remote care should not be to remove the endocrinologist from the patient’s care. The goal should be to make sure the endocrinologist is spending time on the work that only an endocrinologist should do. 

Tellihealth’s clinical team owns that space between the signal and action for your practice. Book a 20-minute discussion. 

Remote Care Works Best When Tech is Surrounded by Care 

A 2025 University of Colorado remote diabetes program offers a useful example. 

Patients with largely uncontrolled type 2 diabetes were contacted every one to two weeks by certified diabetes care and education specialists. The team provided coaching, assessed medication adherence, and made frequent medication adjustments with endocrinologist oversight. 

Among program graduates with follow-up HbA1c measurements, average HbA1c fell from 10.4% to 7.0%. 

Reading collection was helpful, but not the main driver of success here. In reality, it was everything around it. 

• Frequent patient contact.
• Medication review.
• Education.
• Clinical follow-up.
• Specialist oversight. 

The technology generated visibility, which cannot be ignored. But when plugged into more outreach, the care model created action that then created positive outcomes.  

APCM May Help, But it’s Not for Every Endocrinology Practice 

Advanced primary care management (APCM) reflects many of the same principles that chronic care management (CCM) has become famous for. Namely, things like continuity, care planning, and coordination.  

But APCM needs to be discussed carefully in endocrinology. 

CMS describes APCM as a primary-care service. The billing practitioner must be responsible for the patient’s primary care services and serve as the continuing focal point for the patient’s healthcare needs. That means endocrinology practices should not assume that treating diabetes automatically makes APCM appropriate. 

For organizations that operate within a broader integrated or primary-care model and meet the applicable requirements, APCM may offer an additional framework for longitudinal care—especially when considering population management. 

For many endocrinology practices, CCM and connected monitoring may be the more natural place to start. 

The larger lesson is more important than the billing model itself. 

Ultimately, healthcare is moving toward greater accountability for what happens between encounters and endocrinologists cannot ignore that shift. 

The Most Important Moment... Before the A1C Changes 

As a metric, the A1C is irreplaceable. As a provider, there is no replacing the endocrinologist. As a touch point, there is no replacing the visit.  

That being said, is there room in the specialty for a system that catches more of the story before the next retrospective measure tells us what has already happened. Yes, there is.  

For the best delivery of care and health outcomes, the practice needs to gain the ability to respond before the next appointment becomes the first time anyone realizes something has gone wrong. 

Endocrinology Needs a Windshield, Not Just a Rearview Mirror 

While the A1C remains indispensable, the future of diabetes care cannot rely entirely on retrospective measures and episodic visits. Endocrinology truly needs both. 

The rearview mirror tells the care team what happened, very important information, and now longitudinal care can help show what is happening now. 

With Tellihealth connected devices can surface signals; CCM can create context and continuity, and APCM, where appropriate, can support a broader model of accountable care. 

And endocrinologists can remain focused on the clinical decisions that require their expertise. 

Want to see what the future of endocrine care looks like for your patients? Book a demo and we’ll show you. 

Frequently Asked Questions 

How can Chronic Care Management support diabetes patients? 

Chronic Care Management can provide ongoing support between visits for eligible patients managing diabetes and other chronic conditions. CCM may include medication support, care coordination, patient education, follow-up, review of barriers, and escalation of concerns to the provider when needed. 

Why is between-visit care important for endocrinology? 

Diabetes changes continuously, while specialty visits happen intermittently. Problems involving medication adherence, glucose trends, access to prescriptions, diet, other chronic conditions, and patient understanding may emerge weeks before the next endocrinology appointment. Between-visit care can help identify and address those issues sooner. 

What is the benefit of combining CCM with connected devices? 

Connected devices can provide objective physiological data while CCM provides the human context behind that data. Together, they can help a care team understand both what may be changing and why, leading to more focused patient outreach and more meaningful provider escalation. 

Can remote care help reduce endocrinologist workload? 

A well-designed program can allow routine outreach, adherence support, education, care coordination, and initial review of patient issues to be handled by an appropriate clinical team. Endocrinologists can then focus more of their time on complex decisions that require specialist expertise. 

Is Remote Patient Monitoring useful for diabetes care? 

Remote monitoring can be useful when patient-generated physiological information is connected to a clear clinical workflow. The value comes not only from collecting readings but from having a defined process for review, patient communication, follow-up, and escalation. 

Can endocrinologists use Advanced Primary Care Management? 

APCM is intended for practitioners who are responsible for the patient’s primary care services and serve as the continuing focal point for their broader healthcare needs. Endocrinology practices should evaluate their specific model and CMS requirements rather than assuming diabetes management alone qualifies a practitioner for APCM. 

Does remote care replace endocrinology visits? 

No. Remote care is best used to support the patient between visits. It can help identify concerns, maintain continuity, and provide better context so that specialist visits can focus on the decisions that require endocrinology expertise. 

What should an endocrinology practice look for in a remote-care model? 

Practices should evaluate more than the technology. Important questions include who engages patients, who reviews incoming information, how adherence issues are addressed, what gets escalated, how care is documented, how provider workload is protected, and whether the program can scale as patient volume grows.