Workflow GuideeClinicalWorks

eClinicalWorks APCM Care Plan Creation Guide

Master APCM care plan creation in eClinicalWorks. Optimize your eCW workflow for Chronic Care Management and billing compliance.

Developing a robust Advanced Primary Care Management (APCM) care plan within eClinicalWorks (eCW) requires a strategic combination of clinical documentation, population health tools, and automated patient engagement. This guide outlines the technical steps to configure eCW for APCM success while leveraging AI to handle the heavy lifting of patient outreach and data gathering.

The Challenge

Most eClinicalWorks practices find the native Care Management module complex to configure, resulting in manual data entry bottlenecks and missed billing opportunities for chronic care services that require consistent, documented care plan updates.

Step-by-Step Workflow

Identify APCM Candidates via eCW Registry

Utilize the eClinicalWorks Registry or HEDIS dashboards to filter your patient population by chronic condition counts and last visit dates to identify those eligible for APCM G-codes.

Best Practices

Save a custom registry filter specifically for APCM eligibility
Cross-reference with insurance eligibility in the eCW Billing Dashboard

Common Pitfalls

Failing to exclude patients already enrolled in conflicting CCM programs

Configure APCM-Specific SmartForms

Develop or import custom eCW SmartForms that map directly to APCM requirements, ensuring that social determinants of health (SDOH) and care goals are captured as structured data.

Best Practices

Link SmartForm fields to the 'Care Plan' section of the Progress Note
Use keywords to trigger automatic time tracking

Common Pitfalls

Using generic templates that don't satisfy CMS documentation audits

Automate Intake via AI Call Center

Deploy Tile Health’s AI call handling to reach out to eligible patients. The AI gathers updated medication lists and social needs, then pushes this data into the eCW 'S' or 'Care Plan' section via API.

Best Practices

Schedule AI calls 48 hours before the care plan review
Enable the AI to update the 'Reason for Visit' to APCM Enrollment

Common Pitfalls

Relying on clinical staff to make manual enrollment calls

Initialize the Care Management Module

Open the eCW Care Management module for the selected patient and create a new APCM episode. Ensure the 'Care Coordinator' field is assigned to the appropriate staff member for tracking.

Best Practices

Use the 'Action Item' feature to set reminders for monthly follow-ups
Ensure the 'Care Plan' flag is visible in the Patient Hub

Common Pitfalls

Creating care plans in the Progress Note only without an active Episode

Finalize and Sync to Healow

Review the clinical goals and finalize the care plan. Use the eCW 'Publish' feature to ensure the updated care plan is immediately available to the patient via the Healow portal.

Best Practices

Set an automated Healow message to notify the patient of the new plan
Verify the PDF version is attached to the patient document folder

Common Pitfalls

Forgetting to share the plan with the patient, which is a CMS requirement

Execute APCM Billing Codes

Apply the appropriate G-codes within the eCW billing module. Ensure the time spent by both clinical staff and the AI system is aggregated for the monthly billing cycle.

Best Practices

Use eCW 'Billing Alerts' to prevent submission without a signed care plan
Audit the 'Encounter Dashboard' for unbilled APCM episodes

Common Pitfalls

Under-reporting time spent on non-face-to-face care coordination

Expected Outcomes

Reduction in manual care plan documentation time by 40%

100% compliance with CMS APCM documentation requirements

Increased patient engagement through automated Healow portal updates

Higher capture rate of eligible APCM patients via Registry automation

Frequently Asked Questions

Yes, Tile Health uses eCW-compatible APIs to push patient-reported data and screening results directly into the structured data fields of the care plan.

You can use the 'Care Management Timer' feature in eCW or log minutes via custom 'Action Items' that aggregate into the monthly billing report.

While eCW provides default CCM templates, we recommend customizing a 'SmartForm' specifically for APCM to capture SDOH and patient-centered goals efficiently.

CMS requires that the care plan be accessible to the patient. Using Healow is the most efficient way to satisfy this requirement within the eCW ecosystem.

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