ID APCM Care Plan Documentation Checklist

Document that the patient has a complex chronic condition like HIV/AIDS or multiple infections requiring long-term management.

Capture verbal or written consent for APCM services, utilizing AI-assisted phone enrollment to streamline the process for remote patients.

Confirm the patient meets CMS criteria for Infection-Associated Chronic Conditions (IACCI) for post-infectious syndromes like Long COVID.

Document eligibility for Ryan White funding to ensure APCM billing does not conflict with existing grant-funded care coordination.

Identify social determinants of health, such as housing instability or food insecurity, that impact adherence to infectious disease protocols.

List all current medications, including dosage and frequency, specifically focusing on antiretroviral or Hepatitis B antiviral therapy.

Establish specific clinical targets for viral suppression and immune reconstitution, including scheduled lab intervals.

Record status for Hepatitis A/B, Pneumococcus, and seasonal vaccines essential for immunocompromised patient safety.

Perform and document a comprehensive review of potential interactions between ID medications and treatments for comorbidities.

Outline the protocol for prophylactic treatments based on current CD4 counts or other relevant clinical markers.

Implement AI-powered call handling to contact patients who miss ART refills or fail to confirm laboratory appointments.

Document ongoing communication with pharmacies regarding long-acting injectable treatments and prior authorizations.

Record coordination with cardiologists or endocrinologists for managing metabolic side effects of long-term HIV therapy.

Use AI voice systems to triage patient-reported symptoms, ensuring urgent infectious concerns are escalated to a provider immediately.

Log all minutes spent on care coordination, including time spent reviewing AI-generated adherence reports and lab results.