Workflow GuideOracle Health (Cerner)

APCM Enrollment Workflow for Oracle Health (Cerner)

Streamline APCM enrollment in Oracle Health (Cerner) using HealtheIntent and AI automation to improve chronic care management and multi-facility billing.

Optimizing APCM enrollment within the Oracle Health (Cerner) ecosystem requires a precise blend of HealtheIntent data analytics and PowerChart documentation. This guide outlines the end-to-end workflow to identify, consent, and enroll eligible chronic care patients while ensuring compliance with CMS requirements and multi-facility billing rules.

The Challenge

Many health systems struggle with the transition from inpatient to outpatient APCM workflows in Cerner, leading to missed enrollment opportunities and fragmented documentation that fails to meet CMS audit standards across multi-facility environments.

Step-by-Step Workflow

1

Identify Eligible Patients via HealtheIntent

Use HealtheIntent population health analytics to pull registries of patients with two or more chronic conditions, filtering by recent outpatient encounters in Cerner to ensure eligibility.

Best Practices
  • Sync HealtheIntent daily to capture new diagnoses.
  • Filter by attribution to specific outpatient NPIs.
Common Pitfalls
  • Relying on inpatient discharge data alone for outpatient APCM identification.
2

AI-Driven Outreach and Pre-Screening

Deploy AI call handling to reach out to identified patients, explaining APCM benefits and pre-screening for interest before clinical staff intervention to save resource time.

Best Practices
  • Configure AI to handle common questions about APCM costs.
  • Use the patient's preferred language settings from PowerChart.
Common Pitfalls
  • Manual cold-calling which drains nursing resources and reduces enrollment velocity.
3

Capture Verbal or Written Consent in PowerChart

Document patient consent within a dedicated APCM PowerForm or dynamic documentation template to ensure the timestamped entry meets CMS requirements for enrollment.

Best Practices
  • Use a standardized 'APCM Consent' note type for easy auditing.
  • Ensure the consent mentions 24/7 access to care.
Common Pitfalls
  • Storing consent in a non-searchable scanned PDF document rather than a discrete data field.
4

Initiate the Comprehensive Care Plan

Develop the APCM care plan within the Cerner Care Management module, linking specific goals to HealtheIntent risk scores and existing clinical data for a holistic view.

Best Practices
  • Leverage Cerner SmartTemplates to pull in current medications automatically.
  • Share the plan via the HealtheLife patient portal for engagement.
Common Pitfalls
  • Creating a care plan that is not accessible to the multi-disciplinary team in PowerChart.
5

Configure Multi-Facility Billing Attribution

Set up the billing encounter in Cerner ProFit to ensure APCM codes are attributed to the correct outpatient facility rather than the host hospital system.

Best Practices
  • Verify facility-specific NPIs in the provider master file.
  • Automate claim scrubbing for APCM-specific modifiers.
Common Pitfalls
  • Incorrectly billing under an inpatient cost center, leading to claim denials.
6

Establish 24/7 Care Access via AI

Integrate AI phone automation to provide patients with 24/7 access to their care team, satisfying the APCM requirement for continuous availability without increasing staff overhead.

Best Practices
  • Route urgent calls to the on-call provider via Cerner Message Center.
  • Log all after-hours interactions automatically in the patient record.
Common Pitfalls
  • Failing to document after-hours access, risking CMS non-compliance during audits.

Expected Outcomes

1

Increased APCM enrollment rates through automated outreach

2

Improved documentation accuracy within Cerner PowerChart

3

Reduced administrative burden on clinical staff

4

Enhanced compliance with CMS multi-facility billing rules

5

Seamless integration between HealtheIntent and outpatient workflows

Frequently Asked Questions

HealtheIntent aggregates data from across the Cerner ecosystem to identify patients with multiple chronic conditions who meet CMS criteria, even if their data is spread across different facilities.

Yes, by configuring specific outpatient encounter types and using facility-specific PowerForms, practices can manage APCM independently of inpatient workflows.

AI solutions interface with Oracle Health APIs to trigger outreach based on HealtheIntent registries and write back interaction logs directly into the PowerChart.

CMS requires a comprehensive care plan, documented consent, and 24/7 access. Using standardized Cerner templates ensures these elements are easily retrievable for audits.

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APCM Enrollment Workflow for Oracle Health (Cerner) | Tile Health