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Launching an In-house APCM Program: Challenges and Considerations

CMS’s newest program, Advanced Primary Care Management (APCM), has already shown promising results for improving quality measures, patient outcomes, and practice revenue. According to ChartSpan, the average projected revenue for a practice with 1,000-APCM eligible patients is $288,000* per year.

If APCM follows a similar trajectory to Chronic Care Management, which has many of the same features, it could reduce hospital readmissions and overall patient costs. The program is also uniquely qualified to address quality measures. Population health analytics and participation in an ACO, APM or the Value in Primary Care MVP are mandatory elements of APCM. 

However, added service elements like participation in a quality program and population health analytics are part of the reason it’s challenging to launch an APCM program, especially in-house. The program has specific technology, staffing, and compliance requirements that you must fulfill to launch the program successfully, serve your patients, and receive reimbursements for your claims. 

*Results may vary by provider. 

Requirements of an APCM Program

Advanced Primary Care Management is available to all Medicare beneficiaries, regardless of their number of chronic conditions. This sets APCM apart from other care management programs, like Principal Care Management or Chronic Care Management, which specify how many conditions patients must have.

However, APCM comes with an additional requirement to assign patients to levels, each with its own code. 

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 (QMB) 

In addition to the requirement to identify what level patients belong in, APCM adds service elements that other care management programs don’t have. This makes the program highly effective for patients but can make it complicated to launch. 

APCM Service Elements

APCM combines select service elements from programs like Chronic Care Management, Primary Care Management, and Transitional Care Management with other elements that are unique to APCM. 

Here are the service elements you will need to have in place to launch a program: 

1. Obtain patient consent to enroll in APCM

2. Hold an initiating visit for patients not seen within the past 36 months

3. Provide 24/7 access to care team for urgent needs

4. Offer comprehensive care management with assessments, preventative care, and medication reconciliation and management

5. Build a comprehensive, electronic, patient-centered care plan

6. Coordinate care transitions, including referrals to other clinicians and follow-up after emergency department visits and discharges from hospitals or skilled nursing facilities
7. Provide in-home and community-based care, including partnerships with community organizations

8. Offer two-way, digital communication 

9. Utilize population health analytics to identify gaps in care, design interventions, and test those interventions

10. Evaluate success based on quality measure performance under the Value in Primary Care MVP, an ACO, or another Alternative Payment Model 

To successfully fulfill all of these service requirements, you will need to set up a complex and ongoing enrollment process, ensure you have enough staff to manage 24/7 inbound care and proactive outbound care, implement a discharge management program, and create workflows to fulfill quality requirements. 

Enrollment for APCM Programs

Although APCM is open to all Medicare beneficiaries, the enrollment process still requires data parsing technology and an experienced team to introduce the program to patients. 

In addition to being Medicare eligible, eligible patients must have seen their provider within the past 36 months to be enrolled without an initiating visit. Once your enrollment team has determined whether a patient is APCM-eligible, they must also determine whether they qualify for Level 1, Level 2, or Level 3 services.

Because APCM requires consent, you will need to reach out to patients, explain the program, share the compliance requirements, and ask if they want to enroll. If you partner with a care management vendor, they may have a dedicated team to perform this process.

When managing enrollment in-house, you will need to assign staff members to identify patients, reach out to them, and share all of the requirements: 

• There may be a copay and deductibles do apply (except for Level 3 patients) 
• Patients can unenroll from the program at any time, for any reason
• Patients can only enroll under one provider
• The APCM provider agrees to serve as their primary point of care

The patient’s APCM provider does not need to directly perform their services but does need to offer general supervision, incident to.

Once a patient consents to join the program, the enrollment team should record their consent and begin offering the patient services. However, the enrollment process doesn’t end there. New patients continually become eligible for APCM as they join Medicare or switch to your practice for services. 

Patients will also churn out of the program due to moving to another practice, entering a nursing home or long-term care facility, or passing away. Additionally, patients may change levels if they are diagnosed with another condition or move in or out of the Qualified Medicare Beneficiary program.

One practice that launched APCM, Fairfield Medical Associates, shared that gaining access to the HETS database to determine which patients were Qualified Medicare Beneficiaries was a benefit of partnering with a care management vendor. ChartSpan generated a list of patients eligible for Level 3 according to HETS, and Fairfield staff reviewed and approved the list.

If you plan to do APCM in-house, you will need to ensure you can pull eligibility data from your EHR and cross-reference it with the HETS database on a regular basis. 

Planning Inbound and Outbound Care for APCM 

Advanced Primary Care Management requires practices to offer patients both proactive care outreach and 24/7 care access. Practices providing APCM will need a system and sufficient staff to schedule outbound outreach for all enrolled patients, while also staffing a 24/7 phone and text line that is available even when the practice is closed. 

Proactive Care Outreach

Unlike other care management programs, such as Chronic Care Management, APCM does not set time requirements for how much preventive care must be offered each month. Instead, reimbursement is based on service availability.

However, a dedicated care manager who provides preventive care, a care plan and care goals are still critical elements of APCM. Therefore, you’ll need a team of care managers who can create and update the electronic care plan, reach out to patients using digital, two-way methods like phone, text, or email, and provide screenings and assessments for all enrolled patients on a regular basis.

These proactive outreaches are especially critical for Level 3 patients, who often require assistance with Social Determinant of Health (SDOH) resources to achieve their health goals and prevent symptom escalations. For example, it’s difficult for a patient to eat healthily unless they have consistent access to affordable, fresh food, which a care manager can assist with. 

However, Fairfield Medical Associates also noted the benefits of APCM for Level 1 patients, who are often left out of care management. “It opens up the program to Level 1 patients to get them involved in preventive care before issues come up down the road,” said Sarah Lewis, Billing Manager for Fairfield. 

If you don’t currently have staff with time to manage preventive care for Level 1, 2, and 3 patients, you will either need to partner with a vendor or hire enough new staff members to run the program. 

24/7 Care Availability

In addition to outbound care, APCM requires that you offer patients access to care 24/7, including on evenings and weekends. A phone or text care line meets this requirement but will need additional employees who are not managing outbound outreach..

You will also need queuing technology to separate the types of calls, so that patients needing urgent care are not kept waiting for long periods. ChartSpan recommends an average waiting time of no longer than 30 seconds, though individual programs can vary.

Calls to the care line can take a wide variety of forms. Sometimes patients will need logistical help, like:

• Refilling prescriptions
• Scheduling appointments
• Receiving education for their care goals
• Finding community resources

These requests can be managed by clinical staff members. However, sometimes patients will call the care line with unexpected symptoms. In those cases, it’s important to have registered nurses ready to perform triage according to established triage protocols. 

Nurse Triage and the 24/7 Care Line

ChartSpan RNs use Schmitt-Thompson triage protocols for the care line. Whether you choose that triage system or another, you will need to have sufficient RNs on call to address emergency or urgent cases and to direct patients to the correct level of care.

After Schmitt-Thompson triage, ChartSpan saw that 70% of patients who originally intended to visit the ER were redirected to urgent care or their provider’s office. These triage protocols reduce overutilization of the ER and protect patients from stressful, time-consuming unneeded ER visits.

In emergencies, such as when patients have early symptoms of a heart attack or a stroke, triage nurses can call emergency services or remain on the phone with the patient while they or a loved one calls emergency services. This care increases patients’ chances of receiving quick, accurate treatment, which can be life-saving. For example, care managers can inform EMS if patients are having symptoms of a stroke so the hospital is prepared to quickly administer recombinant tissue plasminogen activator (TPA) if indicated.

Because fast responses are so critical in emergency situations, it’s essential that the APCM care line always have triage nurses on call. Preparing sufficient staffing for the 24/7 care line is a critical component of launching Advanced Primary Care Management. 

Offering Discharge Management for Patients

Advanced Primary Care Management also requires practices to offer support after hospital or inpatient discharges. Transitioning from full-time care to at-home care is difficult for many patients, who are at increased risk for readmissions or symptom escalation during this period. 

APCM addresses this risk by requiring care managers to reach out to patients within 48 hours of discharge to offer them assistance. If patients respond to the outreach, the care manager can help them schedule an in-person appointment with their provider.

The care manager can also check on whether patients understand their new care plan and ensure needed prescriptions and durable medical equipment are ordered and delivered. If patients require assistance with meals or finding transportation to appointments or pharmacies, care managers can direct them to resources in their local communities. 

Setting Up Discharge Management

To successfully set up a discharge management program, your practice will need technology that notifies you when patients have been discharged from the hospital. While many health systems have this technology within their own system, it’s important to receive notifications when patients have been discharged from hospitals outside of your health system as well.

Some vendors, such as ChartSpan, have access to nationwide databases of hospital discharges. If your practice doesn’t have this and isn’t working with a vendor, you’ll need an alternative method of identifying discharges.

You will also need established workflows and enough staff to perform discharge management within the 48-hour time frame. By setting up an effective discharge management program, you can lower your patients’ risk of readmissions and keep providers informed about patients’ health statuses. 

Population health and quality measures

While many Medicare care management programs can assist with quality measures, Advanced Primary Care Management makes population health analytics and participation in a quality program mandatory. 

If your practice is a member of an ACO or an Advanced Alternative Payment Model (AAPM), that can qualify as your quality program. If you are a MIPS-eligible clinician who isn’t in an ACO or an AAPM, you will be required to switch to the Value in Primary Care MIPS Value Pathway.

As of 2026, the Value in Primary Care MIPS Value Pathway includes quality measures such as: 

• Diabetes: Glycemic Status Assessment Greater Than 9%
• Screening for Depression and Follow-Up Plan
• Controlling High Blood Pressure 
• Adult Immunization Status

Many ACOs have their own quality measures they track, such as diabetic eye exams, cognitive assessments, smoking cessation screening, and cancer screenings for breast or colorectal cancer.

Regardless of which quality program you participate in, you will need to perform population health analytics and identify gaps in care for your patients. Based on which quality measures are most critical for your patients’ health and for your practice, you will then need to choose which quality measures to address during care management touchpoints. 

Many care management vendors have processes in place to identify gaps in care across multiple patients and address them as part of APCM. If you choose not to collaborate with a vendor, you will need to examine your existing quality processes to see how you can incorporate APCM’s specific requirements. 

Considerations Before Launching an In-house APCM Program

Advanced Primary Care Management has the power to improve patient health outcomes and quality measures for your practice, but only if you’re prepared to manage all of its complex requirements.

To launch APCM, you must continuously identify, stratify and enroll eligible patients; successfully manage outbound outreach and a 24/7 care line, with adequate staffing; and set up workflows to address discharge management and quality measures. If you’re worried about staffing, technology, compliance or documentation, consulting with an experienced care management vendor or starting with a simpler care management program may be more effective than building an APCM program from scratch. 

If you’d like to learn more about the process of launching Advanced Primary Care Management, check out the case study with Fairfield Medical Associates, where a Rural Health Clinic explains how they successfully began APCM in collaboration with ChartSpan.