APCM Implementation for Atrial Fibrillation Checklist

Search EHR records for ICD-10 codes I48.0 through I48.92 to find patients who benefit most from continuous care management and monitoring.

Calculate the baseline CHA2DS2-VASc score to determine the medical necessity for anticoagulation and set the monitoring frequency based on risk.

Evaluate the HAS-BLED score to identify patients at higher risk for bleeding complications while on anticoagulants, ensuring safer medication management.

Record verbal or written consent for APCM participation in the patient chart, detailing the 24/7 access to care and regular monitoring schedule.

Use AI-driven phone outreach to contact eligible AFib patients, explaining the program benefits and securing their initial participation in the care plan.

Document secondary conditions such as heart failure or diabetes that complicate AFib management and require integrated care coordination within APCM.

Establish a routine for patients on Warfarin to report INR results via AI voice prompts, allowing for rapid dosage adjustments by the clinical team.

Deploy automated reminders for DOAC medications like Eliquis or Xarelto, as missing even one dose significantly increases the immediate risk of stroke.

Assess the effectiveness of beta-blockers or calcium channel blockers by having the AI system ask patients about their resting heart rate and fatigue levels.

Automate symptom checks for patients on Sotalol or Flecainide to identify potential pro-arrhythmic effects or changes in rhythm stability between visits.

Monitor pharmacy data or patient self-reports to ensure anticoagulation prescriptions are refilled on time, preventing dangerous gaps in therapy.

Configure the AI to ask specific questions about minor bleeding, such as nosebleeds or bruising, to catch early signs of over-anticoagulation.

Schedule automated AI follow-up calls at specific intervals post-ablation to screen for early recurrence of palpitations or shortness of breath.

Implement a 24/7 AI triage line that handles patient concerns about rhythm changes, escalating urgent symptoms like chest pain to the on-call provider.

Monitor for fluid retention or worsening dyspnea in AFib patients who also have heart failure, as rhythm changes often trigger HF exacerbations.

Guide patients through the use of mobile EKG devices or wearable monitors, ensuring high-quality data is captured for physician review during APCM.

Deliver automated educational modules on managing AFib triggers, including the importance of CPAP compliance for patients with obstructive sleep apnea.

Verify that patients undergoing cardioversion have maintained therapeutic anticoagulation for the required period before and after the procedure.