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How an Advanced Primary Care Management Program Can Improve Your Quality Performance

Launched in 2025, Advanced Primary Care Management (APCM) stands apart from older care management services like Chronic Care Management and Principal Care Management. While those programs are tied to minimum monthly time requirements, APCM is the first to measure success based on quality measure improvement. This approach transforms quality measures from a supplementary task into the core purpose of care management.

MIPS-eligible clinicians who would like to offer APCM must participate in the Value in Primary Care MVP or be a member of an Alternative Payment Model (APM). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) don’t have the same requirements as MIPS-eligible providers, but they should also participate in quality programs under APCM. 

By proactively addressing open care gaps and exploring population health interventions, APCM programs can seamlessly improve quality performance while offering patients more comprehensive, consistent care. Let’s explore the quality requirements of APCM and how a program like ChartSpan can help you address them, whether you’re an RHC, an FQHC, participating in an Alternative Payment Model, or switching to the Value in Primary Care MVP. 

Quality Requirements for Advanced Primary Care Management

Advanced Primary Care Management has two requirements that are strongly tied to quality measures and population health:

• Utilize population health analytics to identify gaps in care, design interventions, and test those interventions and
• Evaluate success based on quality measure performance
  • MIPS-eligible clinicians must measure quality through the Value in Primary Care MVP or an Alternative Payment Model (such as ACO Reach or another ACO) 

To address population health analytics, you will need infrastructure that allows you to proactively identify gaps in care across a large patient population, mark patients to target for intervention, reach out to those patients, and collect data on whether they received, declined, or were ineligible for the intervention.

ChartSpan’s APCM program includes technology that searches a network of hospitals, health systems, and pharmacies to identify open care gaps. ChartSpan’s care managers can then address these care gaps with patients, help them schedule vaccinations, appointments or screenings as needed. ChartSpan’s team also reports on the practice’s monthly performance and identifies measures that require additional coordination from providers. 

Systematic population health software can help you identify and address the most relevant, impactful care gaps across your patient population. Whether you’re working with a partner or running APCM in-house, it’s also essential to customize your care management program to address the quality measures that are most relevant to your practice’s APCM-compatible quality program. 

Quality Measures for the Value in Primary Care MVP

If you’re a MIPS-eligible clinician and not a member of an ACO or another Alternative Payment Model (APM), you must join the Value in Primary Care MIPS Value Pathway to participate in APCM. 

MIPS Value Pathways offer streamlined lists of quality measures for providers to choose from, based on the type of care the provider offers. As of 2025, the Value in Primary Care MVP requires providers to select four quality measures, including one outcome measure.

Which quality measures providers can choose from changes from year to year. A few examples of 2025 measures included in the Value in Primary Care MVP are:

• Diabetes: Hemoglobin A1c (HbA1c) >9% (Outcome measure) 
• Screening for Depression and Follow-Up Plan
• Controlling Hypertension/High Blood Pressure (Outcome measure) 
• Adult Immunization Status
• Screening for Social Determinants of Health

Advanced Primary Care Management care managers can assist practices by addressing these quality measures during their regular check-ins with patients. For example, care managers can not only check on patients’ A1C or hypertension readings, but also help them create ongoing care goals to better manage their blood pressure and blood sugar. 

Diabetes: Hemoglobin A1c (HbA1c) >9%

On average, 81.3% of ChartSpan care management patients had well-managed A1C levels, versus 74.7% of patients who were eligible for but didn’t enroll in care management. While that number comes from ChartSpan’s Chronic Care Management patients, it is likely Advanced Primary Care Management will have many of the same effects, since it has so many similar features. ChartSpan care managers check on A1C levels regularly and help patients create care plans to improve their levels over time. 

Screening for Depression and Follow-up Plan

ChartSpan care managers regularly perform initial depression screenings for patients. If a patient has a positive result, ChartSpan will quickly notify the practice so the patient’s provider can perform a complete screening. The provider can then help the patient build a follow-up plan and begin treatment, if needed. The care manager can help ensure the patient is following their treatment plan and adhering to any prescribed medication. 

Controlling Hypertension/High Blood Pressure

ChartSpan care management was also able to help patients manage their blood pressure, with 72% of CCM-enrolled patients achieving well-controlled blood pressure, versus 67.9% of eligible but non-enrolled patients. APCM is likely to show many of the same effects as CCM, through a mixture of regular check-ins, educational information on hypertension, and realistic care goals to help patients manage their blood pressure.

Adult Immunization Status

ChartSpan care managers can pull data from multiple pharmacies, practices and health systems to determine whether patients have received all of the vaccinations recommended for adults. If they are missing pneumonia, seasonal flu, Tdap, or herpes zoster (shingles) vaccinations, their care manager can help them make an appointment or refer them back to your practice to address these gaps in care.

Since patients must receive all four vaccinations to count toward the numerator of the performance measure and raise your percentage score, you should report and engage patients about all four—and ChartSpan can help. 

Screening for Social Determinants of Health 

Care managers can perform screenings for housing, nutrition and financial insecurity, as well as violence within the home, and provide community resources to patients to help meet these socioeconomic challenges. Because care managers talk to patients up to 12 times a year, they have multiple opportunities to build trust, administer screenings, and provide needed resources to help patients protect their health and safety. On average, 34.6% of patients enrolled in ChartSpan CCM received SDOH screening, versus only 13.3% of patients eligible for but not enrolled in care management. 

ChartSpan’s quality team can also assist with many other quality measures from the Value in Primary Care MVP or help you navigate the process of switching from traditional MIPS to the MVP, if you’re a MIPS-eligible clinician considering APCM.

Quality Measures for Alternative Payment Models (APMs) 

Practices who don’t participate in traditional MIPS or MVPs can use their ACO or another Alternative Payment Model (APM) to meet their quality requirement for APCM. Advanced Primary Care Management can accommodate quality measures from the Medicare Shared Savings Program, ACO Reach, ACO Primary Care Flex, and many other ACOs.

CMS initially wrote in the Proposed Rule that APCM would also accommodate Advanced Alternative Payment Models (AAPM) like Making Care Primary and Primary Care First. Since those programs are ending in 2025, it’s unclear what other AAPMs Advanced Primary Care Management will include. However, care management should be able to assist with care measures from new AAPMs as well. 

Advanced Primary Care Management can address any quality measures that overlap with the Value in Primary Care MVP, as well as other quality measures that might be used by ACOs or AAPMs, such as:

• Eye Exams for Identification of Diabetic Retinopathy
• Cognitive Assessments
• Smoking Cessation
• BMI Screening
• Breast Cancer Screening and
• Colorectal Cancer Screening

Screening Referrals

On average, 66.4% of eligible patients enrolled in ChartSpan care management received their diabetic eye exam, as opposed to just 58% of eligible patients who weren’t enrolled in care management.

ChartSpan care managers saw similar success encouraging eligible patients to receive breast cancer screening (60.9%, an increase from 56.4%) and colorectal cancer screening (60.2%, an increase from 53.35%).

Care managers can also evaluate whether patients may need further screening through cognitive assessments. ChartSpan’s care managers can perform telephonic cognitive assessments during monthly check-ins to identify potential patient needs. If a patient has a positive finding on their initial screening, the care manager can then refer them to their provider for additional screening and follow-up care. 

Care Plan Support

Patients may need to update their care plans based on challenges identified during screenings, and care managers can assist with this process. For example, if a patient is having trouble managing their A1c levels, their care manager could support them in setting up goals around a diabetes-friendly diet or exercise plan.

If a patient’s cognitive assessment shows challenges, their care manager could check on whether they’re using safety and memory techniques recommended by their provider or whether the patient has a caregiver the care manager can share information with. 

Other quality measures, like smoking cessation screening and BMI screening, can inspire care goals about quitting smoking or managing weight that may help patients prevent future chronic conditions, as well as manage any conditions they currently have.

Through a combination of referrals and care plan updates, APCM care managers can assist practices with improving their quality measures and patients with improving their long-term health. 

Quality for RHCs in an APCM Program

Rural Health Clinics are not required to join the Value in Primary Care MVP. However, many RHCs are part of ACOs, and those who are not can still benefit from Advanced Primary Care Management’s opportunities to improve their quality scores.

Some common health challenges among rural populations include chronic conditions like hypertension and type II diabetes, high rates of tobacco use, and socioeconomic obstacles to receiving care. APCM care managers can assist with these challenges by regularly checking on patients’ blood pressure readings or A1c levels, collaborating with patients on care goals to manage these levels, and sharing educational information on diabetes and hypertension.

Care managers can also perform smoking cessation screenings and help smokers or smokeless tobacco users create plans for quitting, with their provider’s guidance. Because patients speak to their care managers up to 12 times a year, they will have multiple opportunities to receive SDOH screening and share their challenges with transportation, finding healthy food, utilities, safety at home, and more. 

If the SDOH screening identifies challenges, care managers can direct patients to resources in their local communities to ensure they receive the care they need.

Quality for FQHCs in an APCM Program

Like Rural Health Clinics, Federally Qualified Health Centers do not have to join the Value in Primary Care MVP, though they can join ACOs. Unlike RHCs, FQHCs report quality measures to HRSA through the Uniform Data System.

Although quality measures change from year to year, some quality measures commonly included that care management can assist with are: 

• Breast Cancer Screening
• BMI Screening
• Smoking Cessation
• Colorectal Cancer Screening
• Screening for Depression and Follow-up Plan
• Controlling High Blood Pressure
• Diabetes: Hemoglobin A1c Control

Since these quality measures overlap with those required by the Value in Primary Care MVP and those required by some ACOs, Advanced Primary Care Management is uniquely equipped to address each of them. Care managers can administer screenings, create care goals, provide community resources, and follow up with providers so that patients at FQHCs receive the support they need with these critical quality measures—allowing FQHCs to improve their performance for HRSA. 

Learn More about Quality and Advanced Primary Care Management Programs

With the advent of Advanced Primary Care Management, quality measures have become a required element of care management instead of an optional one. This is good news for practices, who have the opportunity to improve their performance for MIPS Value Pathways, their ACO, or their other quality programs. It’s also good news for patients, who have expanded access to screenings, referrals, and care goals that can help them improve their long-term health. 

But introducing quality management into your practice requires the ability to comprehensively identify care gaps across multiple practices, health systems, and pharmacies, determine which patients need to have care gaps addressed, follow up with patients consistently, and offer referrals for screenings, vaccinations, and appointments. You need technology, infrastructure, and a workforce capable of managing this level of comprehensive quality management.

ChartSpan can help. If you’re interested in launching an Advanced Primary Care Management program, but concerned about how you’ll address the quality management requirements, reach out to us and schedule a meeting.