Workflow GuideInfectious Disease

APCM Care Plan Workflow for Infectious Disease

Streamline APCM care plan creation for HIV, Hepatitis B, and Long COVID patients using AI-driven automation for Infectious Disease practices.

Creating comprehensive APCM care plans for patients with chronic infections like HIV/AIDS or Hepatitis B requires meticulous detail. This workflow leverages AI call handling to capture patient data, monitor medication adherence, and ensure compliance with CMS IACCI guidelines while reducing the administrative burden on Infectious Disease staff.

The Challenge

ID practices often struggle with the heavy documentation requirements for lifelong antiretroviral therapy and the complex monitoring of immunocompromised patients, leading to missed APCM revenue and potential gaps in long-term patient adherence.

Step-by-Step Workflow

1

Identify Eligible IACCI Patients

Utilize AI to scan EHR records for patients with qualifying Infection-Associated Chronic Conditions (IACCI) such as HIV, Hepatitis B, or symptomatic Long COVID who meet the two-condition or single-high-risk criteria.

Best Practices
  • Cross-reference Ryan White program eligibility for dual-enrollment opportunities.
Common Pitfalls
  • Overlooking patients with stable HIV who still qualify under the high-risk chronic condition category.
2

Automated Outreach and Consent

Deploy AI-powered voice agents to contact eligible patients, explain the benefits of the APCM program, and obtain documented verbal consent for chronic care management services.

Best Practices
  • Script the AI to address common privacy concerns regarding HIV status and data security.
Common Pitfalls
  • Failing to document the specific date and time of verbal consent in the EHR.
3

Initial Assessment and SDOH Screening

Use automated screening tools to evaluate Social Determinants of Health (SDOH), specifically focusing on pharmacy access, housing stability, and food security which impact medication adherence.

Best Practices
  • Integrate screening results directly into the care plan to justify APCM complexity.
Common Pitfalls
  • Ignoring the impact of transportation barriers on regular viral load testing.
4

Clinical Goal Setting and Care Plan Drafting

Establish specific clinical benchmarks such as target CD4 counts, viral suppression levels, or liver enzyme stability, and incorporate these into the structured APCM care plan document.

Best Practices
  • Use standardized templates for Hepatitis B monitoring to ensure no screening window is missed.
Common Pitfalls
  • Setting generic goals that do not address the specific infectious pathology.
5

Medication Adherence Protocol Setup

Configure AI triggers to perform monthly check-ins on antiretroviral therapy (ART) or antiviral refill status, providing immediate alerts to the clinical team if a dose is missed.

Best Practices
  • Link the AI call center to the patient's preferred specialty pharmacy for real-time refill tracking.
Common Pitfalls
  • Relying solely on patient self-reporting during quarterly visits.
6

Long COVID and Post-Infectious Monitoring

For patients with post-infectious syndromes, implement automated symptom tracking for fatigue, cognitive dysfunction, and secondary infections to adjust the care plan dynamically.

Best Practices
  • Use a validated symptom scale like the Bell Disability Scale for Long COVID tracking.
Common Pitfalls
  • Underestimating the documentation time required for complex post-viral management.
7

Final Review and EHR Integration

Consolidate all automated data, clinical goals, and patient feedback into a final APCM care plan, ensuring it is accessible to the patient and all members of the care team.

Best Practices
  • Ensure the care plan explicitly mentions 'APCM' to satisfy CMS audit requirements.
Common Pitfalls
  • Storing the care plan in a PDF format that is not easily editable for monthly updates.

Expected Outcomes

1

Higher rates of viral suppression among HIV and Hep B patient populations.

2

Significant reduction in manual staff time spent on routine patient follow-ups.

3

Consistent monthly APCM reimbursement through automated time tracking.

4

Improved patient satisfaction due to proactive outreach and support.

5

Enhanced compliance with Ryan White and CMS documentation standards.

Frequently Asked Questions

Under the IACCI guidance, conditions like HIV/AIDS, chronic Hepatitis B and C, and long-term sequelae of COVID-19 or Lyme disease qualify if they require ongoing management.

Our AI solutions are fully HIPAA-compliant, utilizing encrypted data transmission and secure storage protocols to ensure patient confidentiality is maintained at all times.

Yes, APCM can often be billed in conjunction with Ryan White services, provided that the documentation clearly distinguishes the non-duplicative nature of the care management tasks.

No, the AI handles administrative data collection, adherence monitoring, and outreach, allowing the ID specialist to focus on high-level clinical decision-making and patient interventions.

Ready to transform your infectious disease practice?

See how Tile Healthcare's AI call center can handle scheduling, triage, and patient communication for your practice.

Schedule a Demo
APCM Care Plan Workflow for Infectious Disease | Tile Health