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How to Set Up APCM Services at Your Organization 

Advanced Primary Care Management, launched by CMS in 2025, gives you the opportunity to offer preventive services to all your Medicare patients. But if you would like to set up APCM services at your organization, you’ll need a comprehensive plan to manage APCM’s requirements. 

APCM includes a range of features, from care plans and care goals to population health analytics, resources for socioeconomic needs, a 24/7 care line, and real-time support when patients are discharged from the hospital. 

Implementing APCM at your healthcare organization requires staff, technology and infrastructure that can manage these advanced requirements. Here are a series of steps to help your practice set up APCM services and successfully run the program for your patients. 

1. Understand the program’s eligibility requirements

Advanced Primary Care Management is available to all Medicare patients, whether they have chronic conditions or not. This distinguishes it from other care management programs, like Principal Care Management or Chronic Care Management, which are only available to those with diagnosed chronic conditions. 

However, with APCM, eligibility also includes determining which level of the program the patient qualifies for. APCM has three levels:

Level 1 (G0556): Patients with one or no chronic conditions
Level 2 (G0557): Patients with two or more chronic conditions
Level 3 (G0558): Patients with two or more chronic conditions who are Qualified Medicare Beneficiaries

Therefore, you need to not only determine which insurance and chronic conditions patients have, but also whether or not they are Qualified Medicare Beneficiaries. If you don’t already have the information in your EHR, you’ll need to access the HETS database, or find a vendor who can provide this information before you begin enrollment. 

2. Build a compliant enrollment process

Patients must give their consent to enroll in Advanced Primary Care Management. Once you determine that they are eligible for the program, you’ll need a method to reach out to them, explain all of the compliance requirements, and ask whether they’d like to enroll in order to obtain their consent. 

Educational materials, like brochures or mailers, can help with this process. You’ll also need dedicated staff members who can reach out to hundreds or thousands of your eligible Medicare patients to inform them about the program.

The enrollment team will describe the benefits of the program, like a 24/7 care line, a dedicated care manager, and support after hospital discharges. They will also need to deliver critical compliance details: 

• There may be a copay and deductibles do apply
• Patients can unenroll from the program at any time, for any reason
• Patients can only enroll in care management under one provider
• The APCM provider serves as the patient’s primary source of care

If the patient chooses to enroll, the enrollment team will record and store their consent. Enrollment is an ongoing process, since patients will become eligible for the program as they join Medicare, or leave the program as they move into assisted living, decide it no longer suits their needs, or pass away.

ChartSpan uses a dedicated enrollment team to determine patient eligibility and reach out to patients, so clients don’t have to use their clinical staff for enrollment processes. If you decide to perform the process in-house, you’ll need the technology to determine eligibility and separate patients into levels and staff who are trained to deliver compliance requirements and document patient consent. 

3. Arrange multiple digital communication methods

Advanced Primary Care Management requires practices to give patients multiple digital communication options. Since 24/7 care is also a requirement, you will need to set up a 24/7 phone line, or find a vendor who can set one up. ChartSpan offers 24/7 phone and text access for all enrolled patients.

However, you’ll also need to give patients other ways to reach you, such as email, an online portal, or another way to exchange digital images. Other options for communication methods include digital surveys and telehealth calls. Although CMS does not specify individual methods you must use, they do specify that you must offer two-way digital methods. 

4. Plan for proactive care

To successfully run a care management program, you’ll need to provide each enrolled patient with a care manager who can help them create a care plan and set proactive care goals for managing their health.

Unlike many other care management programs, Advanced Primary Care Management doesn’t require a certain number of minutes spent on care each month. Providers and care managers are given the discretion to adjust how much care patients receive, based on their needs. However, all APCM services, like the 24/7 care line and multiple communication methods, must be available to all patients, and APCM must be provided under General Supervision of the billing provider.

Care managers must also ensure they’re engaging with patients proactively to work on their care goals, address gaps in care, like missing screenings or vaccinations, and provide screenings, like Social Determinant of Health, Activities of Daily Living, and cognitive health assessments. Population health management is a critical element of APCM. 

5. Perform population health analytics

Care management programs have always been able to assist with care gaps and quality measures, but Advanced Primary Care Management adds a new dynamic by making population health analytics a requirement of the program.

To succeed in APCM, you must have the ability to identify care gaps across your entire patient population, then proactively address them. You’ll report your success through your current Advanced Alternative Payment Model or ACO, or, if you use MIPS, through the Value in Primary Care MIPS Value Pathway.

Relying only on the data in your EHR will limit your ability to effectively address care gaps that patients have closed at other locations. Some vendors, like ChartSpan, have access to national, HIPAA-compliant data networks that include other providers, pharmacies, and state and national databases. ChartSpan’s dedicated quality team reviews this data to determine which gaps in care need to be addressed to achieve the greatest improvement in quality measures.

Care managers incorporate quality measures into regular patient check-ins through digital or phone screenings, educational information, and referrals back to the practice where needed. Through these activities, your practice receives the opportunity to improve your quality performance for the Value in Primary Care MVP, your ACO or your AAPM. 

6. Create a plan for care transitions

In addition to its population health requirements, APCM includes a requirement that providers offer care transition services for patients discharged from the hospital or another inpatient setting. To effectively provide this service, you will need notifications when patients are discharged from hospitals both within and outside of your health system.

These notifications can be patient-provided, but ideally, you’ll have an automated system that can pull in discharge notifications from across the U.S. ChartSpan offers access to automated discharge notifications so care managers can follow up without waiting for patients to notify the practice or tell the hospital they have a primary care provider.

ChartSpan care managers follow up within 48 hours of a patient’s discharge to ensure they understand their new care plans and any new medications prescribed. If you plan to do this internally, you will need to ensure you can follow up within this timeframe.

For effective discharge management, care managers will also need to schedule follow-up appointments for the patient and their provider and check on whether patients have all the resources they need. Additionally, care managers can connect recently discharged patients to transportation, food or medication delivery, and durable medical equipment to lower their risk of readmission. 

7. Connect patients to community resources

Even outside of discharge management, connecting patients to community resources is a critical component of Advanced Primary Care Management. In one digital survey administered by ChartSpan to their patients, 26% of care management patients required help with housing and 35% required help with food insecurity.

Care managers need the ability to direct patients to housing resources, meal delivery services or local food pantries, and transportation providers. They may also be called on to find shelters or resources for cases of abuse and neglect and to set provider appointments for patients who need medical advice or at-home care.

Social Determinants of Health are a critical component of the 24/7 care line as well. Nurses need to be available to perform triage for medical needs but also for pressing social needs like homelessness, lack of heat or food, or concerns about abuse. Setting up a 24/7 care line with both care managers and nurses is therefore a vital element of APCM. 

Set Up APCM Services Compliantly and Effectively 

APCM offers exciting potential to provide preventive care to your Medicare patients, ensuring they have care after hospital discharges, access to SDOH resources, proactive care goals, and multiple ways to reach out to you 24/7. But the program requires the technology to manage both inbound and outbound care and to proactively access discharge and population health data.

If you’re not certain whether you’re ready to start an APCM program in-house or whether you should work with a vendor, check out our whitepaper on whether you should launch care management in house or with a partner.