APCM Care Plan Checklist for Multiple Chronic Conditions

Verify the complete drug list including prescriptions from all outside specialists and over-the-counter supplements.

Document a formal review of potential interactions specifically for patients taking 5 or more concurrent medications.

Record patient-reported obstacles such as cost, side effects, or cognitive challenges in managing complex dosing schedules.

Identify and reconcile differing instructions from various providers regarding the same medication or therapeutic class.

Update preferred pharmacy data and confirm if the patient utilizes mail-order services for maintenance medications.

Log recent specialist encounters and integrate their updated treatment recommendations into the central APCM care plan.

Collect and document lab results and imaging from external facilities to prevent redundant testing and monitor condition progression.

Document coordination with home health, physical therapy, or social services as part of the holistic management strategy.

Clearly define and document the primary clinical lead responsible for synthesizing multi-specialty input for the patient.

For patients recently discharged, ensure the care plan is updated with the latest hospitalist recommendations and discharge meds.

Document specific clinical 'red flags' for each chronic condition that should prompt immediate patient contact or ED visit.

Record the presence of living wills, healthcare proxies, and specific end-of-life care preferences in the electronic record.

Evaluate and document Social Determinants of Health such as transportation access or food insecurity that impact condition management.

Assess and record the patient's ability to perform activities of daily living (ADLs) across their multiple conditions.

Ensure the care plan explicitly states how the patient can access clinical support outside of standard office hours.

Log all minutes spent on care coordination, specialist communication, and record review using AI call-tracking tools.

Document that the comprehensive care plan was shared electronically with the patient or their authorized caregiver.

Ensure a valid, dated consent form is on file specifically for APCM services and the associated cost-sharing responsibilities.

Verify that at least three qualifying chronic conditions are coded and active in the patient’s problem list for the billing period.

Attach AI-generated summaries of patient check-ins to the clinical record to satisfy CMS documentation audit requirements.