APCM Patient Enrollment Implementation Checklist

Identify patients with two or more chronic conditions expected to last at least 12 months.

Confirm the patient has been seen by the practice within the last 12-24 months for an E/M visit.

Prioritize mobile and home phone numbers for automated outreach and ensure mailing addresses are current for notification letters.

Categorize eligible patients to prioritize high-risk individuals who benefit most from care management.

Identify patients currently in CCM to manage the transition to APCM billing codes without service gaps.

Develop scripts that explicitly mention 24/7 access, care coordination, and the right to stop services.

Create dedicated fields to capture the date, time, and staff member who obtained the patient's verbal consent.

Set up a workflow to mail the required program information to patients immediately following verbal enrollment.

Establish a clear protocol for documenting when a patient declines or withdraws from the APCM program.

Ensure all enrollment and consent records are stored for at least 10 years to satisfy CMS audit requirements.

Ensure patients are informed of any potential coinsurance or deductible responsibilities associated with APCM.

Utilize AI to handle the initial wave of outreach calls, providing program education and gathering interest.

Schedule automated follow-up calls at different times of day for patients who do not answer the first attempt.

Ensure your automated system can answer common questions about 24/7 access and care team roles.

Establish a path for the AI to transfer complex clinical questions directly to a care coordinator.

Track how many calls result in successful enrollment to optimize scripting and outreach timing.

Automatically export outreach attempts and results into the patient's chart for a complete audit trail.

Develop simple handouts that explain the shift from reactive to proactive care management.

Clearly communicate that APCM provides a direct line to the care team outside of normal office hours.

Describe the care coordinator as a dedicated advocate who helps navigate the complex healthcare system.

Provide front-desk staff with talking points to address patient concerns during check-in.

Use AI to tailor the enrollment conversation based on the patient's specific chronic conditions.

Visualize the journey from 'Eligible' to 'Contacted' to 'Enrolled' to identify bottlenecks.

Designate a staff member to oversee the AI outreach results and manage the enrollment pipeline.

Review enrolled patient charts to ensure all monthly management requirements are being met and documented.

Create a process for periodically reaching back out to patients who initially declined the program.

Track the financial performance of the program against enrollment targets to justify further scaling.