APCM Care Plan Checklist for Depression & Anxiety

Document baseline severity for major depressive disorder or generalized anxiety disorder to justify APCM enrollment and BHI add-on billing.

Complete and document a formal risk assessment for every patient entering the behavioral health track to ensure safety protocols are active.

Identify co-occurring conditions like diabetes or chronic pain that exacerbate mental health symptoms and impact overall patient outcomes.

Document how depression or anxiety impacts daily activities, employment, and social interactions to tailor the care plan objectives.

Record previous antidepressant or anxiolytic trials, psychotherapy history, and any history of treatment-resistant depression episodes.

Establish specific, measurable goals for symptom reduction based on target PHQ-9 and GAD-7 scores over the next 6 months.

List current antidepressants or benzodiazepines with dosage, frequency, and a specific plan for side-effect monitoring and titration.

Document the specific BHI activities, including systematic follow-up and psychiatric consultation contacts, to support add-on revenue.

Include contact information and scheduled sessions with external therapists or counselors to ensure seamless care continuity.

Verify and document that the patient has 24/7 access to care, specifically mentioning AI-powered after-hours call handling for crisis triage.

Set automated reminders for monthly PHQ-9 and GAD-7 screenings to track clinical progress and adjust treatments as necessary.

Utilize automated AI call handling to verify patient compliance with antidepressant regimens and identify barriers to pharmacy refills.

Define a clear protocol for when screening scores increase by 5+ points or when a patient reports worsening anxiety via the call center.

Document barriers such as transportation or financial stress that impede access to mental health services or medication adherence.

Record the formal review of the behavioral health care plan, adjusting for treatment-resistant symptoms or changes in social support.