APCM Care Plan Checklist for Rural Health Clinics

Confirm the patient is actively enrolled in Medicare Part B to ensure RHC payment eligibility.

Identify at least two chronic conditions expected to last 12 months or until death.

Capture verbal or written consent specifically mentioning APCM services and potential cost-sharing.

Document the date of the Annual Wellness Visit (AWV) or IPPE that initiated the APCM service.

Inform the patient how to access care management 24/7, essential for rural patients far from ERs.

Document transportation barriers, food desert status, and distance to the nearest RHC or hospital.

List all medications, including those prescribed by distant specialists in urban centers.

Set measurable goals that account for agricultural work schedules and rural lifestyle constraints.

Identify local faith-based groups, rural transit, or county health programs available to the patient.

Identify specific needs for coordinating care between the RHC and Critical Access Hospitals.

Ensure the system tracks every minute of automated outreach to count toward the 20-minute threshold.

Use AI to document patient-reported outcomes via phone for COPD, hypertension, or diabetes.

Convert phone interactions into structured SOAP notes for the RHC provider to review and sign.

Document the patient's preference for phone-first contact due to limited rural internet access.

Monitor how many automated calls resulted in successful care plan updates versus manual attempts.

Ensure APCM time tracking does not double-count staff time already allocated to other RHC costs.

Ensure the care plan is accessible to all clinicians in the RHC and CAH network 24/7.

Maintain a clear log of time spent on care coordination that occurs outside of the clinic visit.

Document every instance where a patient moved from a hospital back to rural home care.

Keep a secure record of all AI-driven phone interactions for potential Medicare audits.