Workflow GuideEpic EHR

Epic APCM Care Plan Workflow: Integration & Documentation Guide

Master APCM care plan creation in Epic EHR. Optimize MyChart integration, patient registries, and AI-driven workflows for chronic care management.

Implementing Advanced Primary Care Management (APCM) in Epic requires a sophisticated blend of registry management, care plan documentation, and patient engagement. This guide outlines the specific technical and clinical steps to leverage Epic's Care Management module alongside AI-powered outreach to ensure compliance, maximize billing accuracy, and improve patient outcomes.

The Challenge

Many health systems struggle with Epic's complex care management configuration, leading to incomplete APCM documentation, missed billing opportunities, and fragmented communication between MyChart and phone-based outreach for chronic care patients.

Step-by-Step Workflow

1

Identify Eligible Patients via Reporting Workbench

Define the APCM patient population using Epic’s Registry Framework. Create a report to filter for patients with multiple chronic conditions who have had a qualifying E/M visit within the last 12 months, ensuring the list is dynamic and updates as new patients meet criteria.

Best Practices
  • Use the 'Population Membership' filter in Reporting Workbench.
  • Cross-reference with the 'Active Problem List' to ensure clinical accuracy.
Common Pitfalls
  • Failing to exclude patients already enrolled in conflicting CCM programs.
  • Relying on static Excel exports instead of dynamic Epic registries.
2

Configure APCM SmartText and SmartForms

Develop standardized care plan templates using SmartText that automatically pull in active medications, allergies, and recent lab results. Build a custom SmartForm within the Care Management module to track the specific CMS requirements for APCM documentation.

Best Practices
  • Incorporate @-links to pull in the patient's most recent vitals.
  • Ensure the template includes a clear section for 'Patient Goals'.
Common Pitfalls
  • Creating templates that are too verbose for clinicians to use efficiently.
  • Forgetting to include the 'Required for Billing' hard stops in the SmartForm.
3

Trigger AI-Powered Enrollment Outreach

Integrate AI call handling with your Epic registry to automate enrollment calls. The AI agent contacts eligible patients to explain APCM benefits and obtain verbal consent, which is then captured and pushed back into the Epic encounter via a discrete data field.

Best Practices
  • Schedule AI calls during windows identified in the patient's 'Communication Preferences'.
  • Use a dedicated 'APCM Enrollment' encounter type for these interactions.
Common Pitfalls
  • Not logging the AI call outcome directly in the Epic chart.
  • Failing to sync AI call logs with the patient's MyChart messaging status.
4

Document the Comprehensive Care Plan

Utilize the 'Living Care Plan' feature in Epic to ensure all multidisciplinary team members can contribute. The care plan must be accessible to the patient via MyChart, allowing them to view their goals and interventions in real-time between visits.

Best Practices
  • Set the 'Plan Visibility' to 'Patient and Proxy' in Epic settings.
  • Use 'NoteWriter' to speed up the documentation of monthly care interventions.
Common Pitfalls
  • Keeping the care plan as a static PDF rather than a discrete Epic module.
  • Neglecting to update the care plan after significant clinical changes.
5

Coordinate MyChart and InBasket Workflows

Ensure that all APCM-related communications are centralized. Use Epic InBasket folders to route patient responses from MyChart or AI call transcripts to the assigned care manager, ensuring no patient request for care plan adjustment is missed.

Best Practices
  • Create a dedicated 'APCM Pool' for InBasket message routing.
  • Use 'QuickActions' to resolve common APCM patient queries.
Common Pitfalls
  • Allowing APCM messages to get buried in the general 'Patient Message' folder.
  • Failing to notify the primary provider of significant care plan updates.
6

Automate Billing via Charge Router Integration

Configure the Epic Charge Router to recognize when the APCM documentation requirements are met. Once the care plan is signed and the minimum monthly interaction occurs, the system should suggest the appropriate G-code or CPT code for the biller's review.

Best Practices
  • Set up 'Best Practice Advisories' (BPAs) to alert staff when billing criteria are met.
  • Review the 'Charge Review' workqueue weekly for APCM-specific errors.
Common Pitfalls
  • Manually entering billing codes, which leads to frequent keystroke errors.
  • Ignoring the 'Time Tracking' logs within Epic encounters.

Expected Outcomes

1

Reduced administrative burden on care managers through AI-driven enrollment and data entry.

2

100% compliance with CMS APCM documentation requirements within the native Epic environment.

3

Improved patient engagement scores via seamless MyChart integration and proactive AI outreach.

4

Increased revenue capture through automated billing triggers and accurate registry management.

5

Enhanced clinical coordination between primary care providers and chronic care specialists.

Frequently Asked Questions

Consent is typically captured using a specific SmartForm within a Telephone or Office Visit encounter. This data is stored discretely, allowing for easy reporting and ensuring that billing is only triggered for consented patients.

Yes, by using Epic's Interconnect (API) or HL7 interfaces, AI call logs and transcripts can be routed directly to specific InBasket pools or folders for care manager review and sign-off.

Standardized SmartTexts and SmartForms are typically preserved, but it is critical to perform regression testing in the TST environment to ensure that custom registries and Charge Router rules continue to fire correctly.

Epic includes a 'Time Tracking' activity that can be added to encounters. For APCM, this can be automated to aggregate time spent on MyChart messaging, chart review, and AI-assisted patient outreach.

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Epic APCM Care Plan Workflow: Integration & Documentation Guide | Tile Health