Workflow GuideValue-Based Care

APCM Care Plan Workflow for Value-Based Care Success

Optimize APCM care plan creation to drive VBC outcomes, improve HEDIS scores, and maximize shared savings through automated patient engagement.

Advanced Primary Care Management (APCM) serves as the strategic foundation for practices transitioning to value-based care. By establishing a comprehensive care plan workflow, providers can bridge the gap between fee-for-service revenue and long-term population health outcomes. This guide outlines the essential steps to integrate APCM into your VBC framework, leveraging AI-driven call handling ...

The Challenge

Many practices struggle to scale APCM care plans due to administrative burdens and manual outreach, leading to missed quality metrics, inaccurate risk adjustment, and lost shared savings opportunities in VBC contracts.

Step-by-Step Workflow

1

Identify High-Risk Populations via Risk Stratification

Use EHR data and AI analytics to identify patients with multiple chronic conditions who qualify for APCM and impact ACO performance metrics.

Best Practices
  • Focus on HCC coding accuracy
  • Automate high-risk list generation
Common Pitfalls
  • Ignoring rising-risk patients
  • Relying on manual chart reviews
2

Conduct AI-Assisted Patient Intake and SDOH Assessment

Utilize automated phone systems to gather initial health status updates and social determinants of health data before the clinical encounter.

Best Practices
  • Standardize SDOH questions
  • Integrate intake data directly into EHR
Common Pitfalls
  • Failing to capture non-clinical barriers
  • Overwhelming staff with manual intake calls
3

Develop Personalized VBC-Aligned Care Goals

Create specific, measurable goals that align with HEDIS measures and the patient’s long-term health objectives to ensure medical necessity.

Best Practices
  • Link goals to specific quality metrics
  • Use patient-centered language
Common Pitfalls
  • Creating generic care plan templates
  • Ignoring patient-reported priorities
4

Implement Care Gap Identification and Closure

Review the care plan against evidence-based guidelines to identify missing screenings, using AI to schedule follow-up appointments automatically.

Best Practices
  • Automate recall for annual screenings
  • Track gap closure rates in real-time
Common Pitfalls
  • Failing to document gap closure for MIPS
  • Inconsistent follow-up on referrals
5

Establish Continuous Monitoring and AI Outreach

Set up automated check-ins to monitor care plan adherence, medication compliance, and symptom changes between scheduled office visits.

Best Practices
  • Use clinical escalation protocols
  • Track engagement metrics for VBC reporting
Common Pitfalls
  • Infrequent patient contact
  • No system for identifying acute status changes
6

Document Quality Measures for MSSP and MIPS

Ensure all care plan elements are documented according to CMS standards to support shared savings and regulatory compliance.

Best Practices
  • Audit documentation weekly
  • Use standardized VBC templates
Common Pitfalls
  • Incomplete time-tracking for APCM billing
  • Missing links between care and quality metrics

Expected Outcomes

1

Improved HEDIS and MIPS quality scores

2

Increased shared savings through reduced TCOC

3

Enhanced patient engagement and adherence

4

More accurate HCC risk adjustment coding

5

Scalable chronic care management infrastructure

Frequently Asked Questions

APCM focuses on the advanced primary care model, emphasizing population health and quality outcomes over simple time-based billing requirements.

Yes, AI-powered systems provide consistent, proactive outreach that manual staff cannot scale, ensuring patients follow their personalized care paths.

Addressing social determinants is critical for VBC success, as it identifies barriers to care that impact total cost of care and clinical outcomes.

By monitoring care gap closure rates and emergency department utilization among your APCM-enrolled population compared to historical benchmarks.

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APCM Care Plan Workflow for Value-Based Care Success | Tile Health