Endocrinology, across the board, has a capacity problem. As diabetes prevalence continues to rise, patients are becoming more complex. And while more physiological data is available than ever before, the supply of endocrinologists is not expanding fast enough to make the traditional model of specialist-led, appointment-centered care infinitely scalable. 

The answer cannot simply be to send endocrinologists more information (another glucose report, portal message, dashboard, etc.) All that does is add work for people—who are not available—to review. 

It’s become obvious. The future of diabetes care requires a different operating model. We propose one where endocrinologists remain responsible for the decisions that truly require endocrinology expertise, while a broader care infrastructure supports patients through the hundreds of decisions, problems, questions, and changes that happen between specialist visits. 

Enter longitudinal remote care models such as chronic care management (CCM), advanced primary care management (APCM), where appropriate, and connected physiological monitoring become increasingly important. 

Because now, more than ever, diabetes needs more continuity, not more technology. 

Table of Contents: 

• As It Stands: Endocrinologists are the Entire Care Infrastructure
• Endocrinology Does Not Have a Lack-of-Data Problem 
• The A1C is a Rearview Mirror, An Example
• CCM Creates Something Diabetes Care Desperately Needs: Continuity
• Connected Devices Can Make CCM Even More Actionable
• More Data Can Create More Work
• APCM Adds Another Possibility
• The Future of Endocrinology is Not Replacing the Visit 

As It Stands: Endocrinologists are the Entire Care Infrastructure 

At Tellihealth, we prefer to let them be the escalation point, since diabetes is not managed during four appointments a year. It's managed on a Tuesday morning when a patient wakes up sweating with an unexpectedly low glucose reading or when the cost of a crucial medication becomes too expensive or when their blood pressure is sitting a little too high.  

Diabetes is managed in the moments where readings start moving in the wrong direction weeks or months before the next scheduled appointment. 

These events may eventually reach the endocrinologist, but the appointment is not where the issue lies.  

Today, in most practices, traditional specialty care asks a relatively small number of appointments across a year to carry the weight of an extraordinarily complex disease. Even when services and programs work to expand access, the fundamental challenge remains.  

Somebody has to own what happens between encounters. 

A 2025 University of Colorado diabetes remote-care program illustrates what a different model can look like. Patients with primarily uncontrolled type 2 diabetes were contacted every one to two weeks by certified diabetes care and education specialists. Those specialists provided coaching, assessed medication adherence, and made frequent medication adjustments with endocrinologist oversight. Among 106 program graduates with follow-up HbA1c measurements, average HbA1c fell from 10.4% to 7.0%. 

Technology mattered but look at what actually surrounded it. 

• Frequent contact
• Medication management
• Education
• Follow-up
• Clinical oversight 

In other words, the outcome was not created by a stream of data alone. It was created by an operating model that gave someone responsibility for acting on what the data revealed. 

Endocrinology Does Not Have a Lack-of-Data Problem 

Thankfully, modern diabetes care is becoming extraordinarily information rich. A different age of diabetics and providers could never have imagined the type of information we have access to.  

• CGMs can generate glucose trends throughout the day
• Connected devices can transmit blood pressure, weight, and other physiological measurements
• EHRs contain labs, medication lists, diagnoses, and encounter histories
• Patients send portal messages
• Pharmacies send requests 

But visibility and care are not the same thing. Sadly, a glucose trend cannot call the patient, and dashboard cannot determine that the reason adherence suddenly declined is that the medication became unaffordable. 

A poor blood pressure reading cannot explain that the patient misunderstood their discharge instructions. An A1C will eventually show there was an issue but cannot tell the practice that someone has been taking insulin at the wrong time for three weeks. 

The data highlights a signal, shows that something is going on, but someone still has to determine what the signal means. 

And that is the real opportunity for remote care in endocrinology. 

The next phase of diabetes care should not be defined by how much information a practice can collect. It should be defined by how reliably the practice can turn information into action without making the endocrinologist responsible for every step. 

The A1C is a Rearview Mirror, An Example 

The A1C reading is both essential and a rearview mirror. HbA1c remains one of the most important measures in diabetes management, if not the most important, but by definition, it tells clinicians about glycemic control over a period of time. 

That makes it immensely valuable for understanding what has happened....in the past. 

It is less useful for answering a different question: What is developing right now? 

Consider two different patients with the same data signal. 

Patient #1: Shows up to appointment with higher A1C. 

• Stopped taking medication because of gastrointestinal side effects
• Had to begin a steroid treatment
• Misunderstood bolus instructions 

Patient #2: Shows up to appointment with higher A1C. 

• Has been taking the medication but eating differently after a major life event
• Having trouble affording medication
• Experiencing asymptomatic glucose changes that they never thought to report 

Thankfully, the lab results will tell us there is a problem. But beyond that? There is no context. Conversely, longitudinal care can help uncover the story behind it before months pass. 

A reading can tell the care team: Something has changed. 

A longitudinal care relationship can ask: Why? 

CCM Creates Something Diabetes Care Desperately Needs: Continuity 

CCM with Tellihealth cannot be reduced to a monthly phone call. With us, chronic care management creates an ongoing relationship around the patient. 

“We TRULY know our patients. I can tell you the social and medical history of pretty much any one of my patients, without looking. I know my patients well, and their schedules. Do they work? Are they a morning person or not? Things like knowing the best time to call a patient and when the patient may feel is the best time for them to talk, can be very helpful with calling patients and increasing connectivity!” 

- CCM Nurse G.K. 

Patients may simultaneously be managing hypertension, cardiovascular disease, kidney disease, obesity, neuropathy, medication complexity, mobility limitations, behavioral health concerns, financial barriers, or social challenges that affect their ability to follow a treatment plan. 

The endocrinologist may be responsible for one important part of that picture, and yet the patient's life does not divide itself by specialty. 

A strong CCM model creates room to address questions that routinely influence clinical outcomes: 

• Is the patient actually taking the medication as prescribed?
• Do they understand why they are taking it?
• Are they experiencing side effects?
• Did another clinician change something?
• Did they obtain their supplies?
• Are they following the care plan?
• Are financial or transportation barriers affecting care?
• Did they recently visit the emergency department?
• Do they understand when they should contact the practice?
• Does something need to be escalated? 

That work does not replace endocrinology. It can’t and it shouldn’t, but it does protect it.  

Instead of requiring an endocrinologist to personally discover every barrier, routine issue, or adherence problem, CCM identifies what can be resolved at the care-management level and what genuinely warrants specialist attention. 

“We are only sending the important details, weeding out anything that is not relevant to the patient's care, therefore saving the office time and making it easier for them to give us direction to care for the patient. We have had triage nurses tell us ‘Thank You’ many times for the help we give, because there is no way at all they would be able to follow up with the patients like we do.” 

Tellihealth makes CCM sustainable, scalable, and compliant. Talk to our team today about what we can do for your patients.  

Connected Devices Can Make CCM Even More Actionable 

As providers well know, traditional care management depends heavily on what a patient knows, remembers, notices, and chooses to report—a severe limitation. 

Patients, even the most diligent, will naturally under-report. Sometimes because they don’t recognize a pattern or something as clinically meaningful. Other times, they don’t want to bother anyone. And sometimes because, to them, nothing feels wrong. 

Most often, the burden of remembering several weeks of glucose patterns, blood pressures, medication changes, symptoms, meals, and daily events is unrealistic. Even when they are discussing that on the phone in their own homes.  

Under those circumstances, connected physiological data changes that conversation. 

Instead of: “How have things been since we last spoke?” 

The care team can ask: “Your readings have been trending higher this week. Did anything change?” 

Connected devices can add much needed context. 

More Data Can Create More Work 

There is a dangerous assumption under digital-care strategies: If clinicians can see more information, care will automatically improve. 

Not necessarily.  

Imagine adding thousands of additional readings to an already stretched endocrinology practice. 

• Who reviews them?
• How frequently?
• What constitutes a meaningful change?
• Who contacts the patient?
• Who determines whether the issue is behavioral, medication-related, technical, or clinical?
• Who documents the interaction?
• What gets escalated?
• What does not?
• Who follows up afterward? 

Without answers to those questions, remote monitoring can simply transfer another operational responsibility to the practice. That’s why endocrinology leaders should evaluate remote care as an operating model, not merely as a technology purchase. 

APCM Adds Another Possibility 

One that endocrinology needs to approach it carefully. 

Advanced primary care management (APCM) introduces an additional model for organizations building more comprehensive longitudinal-care infrastructure. 

CMS describes APCM as a monthly bundled service incorporating elements of chronic care management, transitional care management, communication technology, comprehensive care planning, population management, care coordination, and enhanced patient communication. 

The model is attractive because it reflects many of the capabilities modern chronic-disease populations need: continuity, risk stratification, care planning, coordination, remote communication, medication management, and population-level oversight. 

However, APCM is not automatically an endocrinology service. 

CMS states that the billing practitioner must be responsible for the patient's primary care services and serve as the continuing focal point for the patient's needed health care. CMS also notes that APCM codes are primarily intended for primary-care specialties such as internal medicine, family medicine, geriatrics, and pediatrics. 

For the sake of compliance, that distinction should not be ignored. 

For endocrinology organizations that genuinely operate within broader primary-care or integrated-care models and meet the requirements, APCM may deserve consideration. 

For others, CCM and connected monitoring may provide a more natural path for extending longitudinal support. 

The broader lesson matters more than the code: 

Diabetes care is moving toward models that reward ongoing responsibility rather than isolated encounters. 

The Future of Endocrinology is Not Replacing the Visit 

None of this means the endocrinology appointment matters less. In fact, it means the appointment should not be expected to do everything. It’s a novel thought, really. 

The specialist visit is extraordinarily valuable when it is used for work requiring specialist expertise: complex treatment decisions, diagnosis, therapy optimization, difficult cases, and clinical judgment. 

What makes less sense to us is using scarce specialist capacity as the default infrastructure for every routine adherence check, education question, care-coordination task, emerging trend, medication barrier, and follow-up need. 

A better model surrounds the specialist with longitudinal care—that's what Tellihealth provides. 

• Connected devices can provide visibility
• CCM can provide continuity and context.
• APCM can provide a broader advanced-care framework for organizations and practitioners that meet its requirements 

And endocrinologists can remain focused on the decisions only they should be making. That is not replacing specialty care. It is designing the system around the value of specialty care. 

Endocrinologists spent years learning how to see more. Now it needs the capacity to act. Tellihealth will help you do it. Book a 20-minute call to discuss how. 

Frequently Asked Questions 

How can Chronic Care Management help endocrinology practices? 

Chronic Care Management can extend support between endocrinology visits by helping eligible patients manage medications, understand care plans, address barriers, coordinate services, and maintain regular contact with a care team. For patients managing diabetes alongside other chronic conditions, CCM can help practices identify problems that may otherwise remain undiscovered until the next appointment. 

What is the benefit of combining CCM with connected devices? 

CCM provides longitudinal conversations and clinical context, while connected devices can provide objective physiological information between encounters. Together, they can help a care team identify both what is changing and why it may be changing, allowing more focused outreach and more informed escalation to the provider. 

How can remote care reduce endocrinologist workload? 

A well-designed remote-care program can route routine education, adherence support, care coordination, follow-up, and initial review of patient issues through an appropriate clinical team. Problems that require specialist judgment can then be escalated to the endocrinologist rather than making the specialist the first point of contact for every patient need. 

Is Remote Patient Monitoring useful for diabetes? 

Remote monitoring can be useful for appropriately selected patients when physiological data is connected to an effective clinical workflow. A 2025 University of Colorado diabetes remote-care program combined remote monitoring with regular diabetes-specialist outreach, medication assessment, coaching, and endocrinologist oversight and reported substantial HbA1c improvement among program graduates. 

Can endocrinologists bill for Advanced Primary Care Management? 

APCM requires the billing practitioner to be responsible for the patient's primary care services and serve as the continuing focal point for the patient's broader health care needs. CMS states that the codes are primarily intended for primary-care specialties. Endocrinology organizations should therefore evaluate their specific care model and billing circumstances rather than assuming that managing diabetes alone qualifies a practitioner for APCM. 

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

Practices should look beyond the technology itself. Important questions include who engages patients, who reviews information, how medication and adherence issues are addressed, what gets escalated to the provider, how care is documented, how clinical responsibilities are divided, and whether the model can scale without adding unnecessary burden to the endocrinology team. 

Does remote care replace in-person endocrinology visits? 

No. The stronger model uses longitudinal remote care to complement specialist visits. Routine follow-up, patient engagement, monitoring, education, and care coordination can occur between appointments, while endocrinologists remain focused on clinical decisions and cases that require their expertise.