APCM Care Plan Checklist for Family Medicine

Document at least two chronic conditions expected to last 12 months or until death that put the patient at significant risk.

Utilize AAFP-supported risk-stratification tools to categorize patients into high, medium, or low complexity tiers for billing accuracy.

Record verbal or written patient consent for APCM services, including an explanation of cost-sharing and the ability to opt-out.

Confirm the patient has active Medicare Part B coverage and is not currently enrolled in a competing CCM or PCM program.

Screen for SDOH factors such as housing stability and food security that impact family health outcomes and care plan adherence.

List all active chronic conditions with corresponding treatment goals, expected outcomes, and prognosis for each.

Include necessary immunizations, screenings, and preventive services relevant to the patient's age and family history.

Review all active medications, including over-the-counter supplements, and document potential interactions or adherence barriers.

Collaborate with the patient to define measurable health goals that align with their personal values and lifestyle.

In multi-generational households, document the names and contact details of family members involved in the patient's care.

List local resources or specialists that will be utilized to support the patient's comprehensive care needs.

Ensure patients can reach a clinician or care manager at any time, utilizing AI call handling to triage urgent family needs.

Sync all automated outreach and patient inquiry logs directly into the EHR to satisfy documentation requirements.

Use automated systems to conduct monthly check-ins, ensuring the care plan remains current and barriers are addressed.

Provide a HIPAA-compliant portal or messaging system for non-urgent communication between the patient and family practice.

Document all digital communications that contribute to the monthly management of the patient's chronic conditions.

Document all admissions and discharges, ensuring a follow-up is scheduled within the required APCM timeframe.

Record the status of referrals and ensure specialist notes are integrated back into the primary care plan.

Coordinate care with skilled nursing facilities or home health agencies to maintain continuity for elderly family members.

Electronically transmit the care plan to other providers involved in the patient's treatment to ensure alignment.

Perform a formal review of the comprehensive care plan at least once every 12 months or upon significant health changes.