APCM Implementation Checklist for Pulmonology

Use EHR data to flag patients with 2+ exacerbations or 1+ hospitalization in the last 12 months for APCM enrollment.

Establish protocols for patients with two or more chronic conditions like COPD, asthma, or interstitial lung disease.

Deploy AI call workflows to contact eligible patients and explain the benefits of the APCM program and 24/7 access.

Ensure verbal or written consent for APCM participation is recorded in the EHR to meet CMS billing requirements.

Screen all enrolled patients for tobacco use and integrate cessation counseling into the initial APCM care plan.

Create standardized digital action plans that trigger AI-led follow-up calls when peak flow readings drop.

Schedule periodic check-ins via automated phone systems to verify patient adherence and proper inhaler usage.

Coordinate with DME providers through automated workflows to ensure oxygen supplies and flow rates are monitored.

Track attendance and progress for pulmonary rehabilitation, using AI to re-engage patients who miss sessions.

Perform monthly reviews of respiratory medications to prevent contraindications and ensure GOLD guideline compliance.

Implement secure AI call handling to triage respiratory distress calls vs. routine scheduling inquiries.

Ensure patients have round-the-clock access to a care team member or AI assistant for urgent respiratory concerns.

Use automated logs to capture every minute spent on non-face-to-face care coordination for COPD and asthma patients.

Monitor post-discharge follow-up calls within 48 hours of hospital exit to reduce 30-day readmission rates.

Screen for environmental triggers like air quality or mold that may impact chronic respiratory conditions.