Workflow GuideMulti-Site Practices

APCM Care Plan Workflow for Multi-Site Practices

Standardize APCM care plan creation across multiple locations with our workflow guide for MSOs and multi-site practice groups.

Standardizing Advanced Primary Care Management (APCM) care plans across 5-50+ locations requires more than clinical expertise; it demands operational synchronization. This guide outlines how to leverage AI-driven data collection and centralized reporting to ensure every patient receives a high-quality, compliant care plan regardless of which site they visit.

The Challenge

Multi-site practices often struggle with fragmented care plans due to disparate EHR systems, varying provider workflows, and inconsistent patient attribution, leading to significant billing compliance risks and uneven clinical outcomes across the regional organization.

Step-by-Step Workflow

1

Centralized Patient Identification

Utilize AI to scan multi-EHR data to identify eligible patients across all locations, centralizing the enrollment queue for the MSO's APCM team to ensure no patient falls through the cracks during acquisitions.

Best Practices
  • Standardize ICD-10 filters across all EHR instances
  • Prioritize patients with recent hospitalizations
Common Pitfalls
  • Relying on individual site managers to pull lists manually
  • Ignoring patient attribution errors in the master patient index
2

Automated Health Assessment Collection

Deploy AI phone automation to conduct standardized initial health assessments. The AI gathers patient goals, social determinants of health (SDOH), and medication lists to populate the care plan foundation without taxing site-level staff.

Best Practices
  • Use voice AI to handle high-volume outreach simultaneously
  • Ensure assessments are available in multiple languages for regional diversity
Common Pitfalls
  • Overloading front-desk staff with assessment calls
  • Using non-standardized assessment forms across different sites
3

Provider Attribution and NPI Validation

Automatically link each care plan to the correct rendering provider and location-specific NPI. This ensures APCM billing compliance across different regional tax IDs and prevents claim denials due to credentialing mismatches.

Best Practices
  • Maintain a centralized NPI database for all providers
  • Validate provider enrollment in Medicare for each specific location
Common Pitfalls
  • Billing under a central NPI for services rendered at a satellite site
  • Failing to update provider lists after practice acquisitions
4

Multi-EHR Care Plan Integration

Synchronize the generated care plan across different EHR instances using middleware. This ensures that whether a patient visits a legacy site or a newly acquired clinic, their APCM care plan is visible to the treating clinician.

Best Practices
  • Use HL7 or FHIR bridges to connect disparate systems
  • Embed the care plan as a discrete data element, not just a PDF
Common Pitfalls
  • Keeping care plans in a siloed platform outside the main EHR
  • Manual data entry between systems which leads to transcription errors
5

Clinical Review and Digital Signature

Route the AI-drafted care plan to the assigned provider at the specific site for review. The provider confirms the clinical goals and applies a digital signature to meet the 20% clinical time requirement for APCM billing.

Best Practices
  • Batch review tasks for providers to improve efficiency
  • Use automated alerts to remind providers of pending signatures
Common Pitfalls
  • Missing the provider signature date for the billing period
  • Lack of clinical oversight in the automated drafting process
6

Patient Distribution and 24/7 Access

Distribute the finalized care plan to the patient via a secure portal or automated voice summary. Ensure the patient has a clear path to 24/7 access to their care team, a core requirement of APCM regulations.

Best Practices
  • Automate the delivery of the care plan via SMS or Email
  • Link the care plan to a centralized after-hours AI triage line
Common Pitfalls
  • Failing to document that the patient received the care plan
  • Providing a generic office number that is only answered during business hours
7

Site-Level Performance Tracking

Use a centralized dashboard to track care plan completion and enrollment rates by location. This allows MSO leadership to identify underperforming sites and provide targeted training or resource allocation.

Best Practices
  • Compare site performance against regional benchmarks
  • Automate weekly revenue reports for PE stakeholders
Common Pitfalls
  • Only looking at aggregate data instead of site-specific metrics
  • Ignoring the correlation between site staffing levels and APCM success

Expected Outcomes

1

Unified care plan quality across all 5-50+ practice locations

2

Reduced administrative burden on site-level clinical staff by 40%

3

100% compliance with Medicare APCM provider attribution rules

4

Seamless onboarding for newly acquired practice sites within 30 days

5

Real-time visibility into APCM enrollment and revenue targets for MSO leadership

Frequently Asked Questions

We utilize AI-driven middleware to extract and push care plan data into disparate systems, maintaining a centralized dashboard for the MSO while ensuring data is native to each local EHR.

AI automates the initial data gathering through patient outreach, identifies chronic conditions from historical charts, and drafts the clinical goals for provider review, significantly shortening the creation time.

Yes. By using automated NPI mapping and location-based attribution, the workflow is managed by a central team while the revenue is credited to the specific site and provider where the patient is attributed.

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APCM Care Plan Workflow for Multi-Site Practices | Tile Health