APCM Implementation Checklist for Family Medicine

Use EHR reporting tools to pull lists of patients with multiple chronic diagnoses like hypertension, diabetes, or COPD.

Categorize patients into Level 1, 2, or 3 based on clinical complexity and AAFP risk-stratification models.

Confirm patients are enrolled in Medicare Part B and are not currently enrolled in competing programs like TCM or CCM.

Screen for social determinants of health that impact care access, particularly for rural family medicine patients.

Ensure billing software is updated with the latest APCM G-codes and bundled payment structures for Family Practice.

Utilize AI call handling to provide patients with immediate responses and routing to on-call providers after hours.

Set up automated AI check-ins to monitor medication adherence and symptom changes without increasing staff workload.

Create EHR templates that cover whole-family health management and multi-generational care goals.

Use outreach calls to schedule annual wellness visits and preventive screenings alongside chronic care management.

Establish a workflow for 24-hour follow-up after hospital discharge or emergency department visits using automated triggers.

Ensure every patient chart reflects the 13 required APCM components, including systematic assessment and care planning.

Obtain and document informed consent for APCM services, explaining cost-sharing and the ability to opt-out.

Review quality measures to ensure APCM activities contribute to the Value-Based Care performance scores.

Use encrypted platforms for all digital and telephonic communications between the care team and patients.

Shift focus from tracking minutes to documenting the completion of comprehensive care management activities.