Advanced Primary Care Management (APCM): What Healthcare Systems Should Know

Launched in 2025, Advanced Primary Care Management (APCM) is a new value-based care model that Medicare providers and patients are still getting to know. With more than 68 million Americans enrolled in Medicare in 2024, understanding this care model is essential for providers to both identify patients who stand to benefit most and drive better health outcomes across their populations.

We consulted with experts at ChartSpan to understand what APCM is and how healthcare providers across Virginia can leverage it to expand their patient care. In this guide, we’ll outline what you need to know about APCM and how it can benefit healthcare providers.

Transform the way your organization delivers primary care. VHHA Solutions helps hospitals and healthcare institutions implement advanced management strategies that strengthen care delivery and operational performance. Reach out today to see how we can help your team achieve sustainable improvement.

Key Takeaways

Advanced Primary Care Management (APCM) shifts the focus from time-based billing to quality-driven, preventive care for Medicare patients.
The program gives providers greater flexibility through risk-based reimbursement, virtual communication options, and customizable patient outreach.
Partnering with experienced healthcare solution providers simplifies APCM implementation and supports stronger patient and operational outcomes.

What Is Advanced Primary Care Management (APCM)?

Introduced by the Centers for Medicare & Medicaid Services (CMS), Advanced Primary Care Management is a program that helps primary care providers move toward value-based care while maintaining the advantages of fee-for-service reimbursement. By rewarding providers for delivering preventative care to risk-stratified Medicare patients, APCM shifts the focus from service volume to measurable patient outcomes and long-term health improvements. In addition to the positive patient outcomes, this model is intended to help reduce costs linked to avoidable emergency department visits and preventable complications.

Under APCM, providers are reimbursed for offering comprehensive, ongoing services rather than meeting time-based thresholds. This allows for prevention, early intervention, and stronger patient engagement.

There are 10 required service elements that providers must make available to all APCM patients in order to participate in the program. However, providers are not required to provide all services to APCM patients every month. The service elements include:

Patient consent: Inform patients about eligibility, costs, and rights; document consent.
Initiating visit: Required unless the patient was seen within the last three years or recently received care management.
24/7 access to care: Ensure around-the-clock patient access.
Patient-centered delivery: Offer nontraditional options such as home visits or extended hours.
Comprehensive care management: Conduct proactive assessments, prevention, and self-management support.
Care transitions coordination: Communicate and coordinate within seven days of patient discharge from an inpatient setting.
Practitioner, home, and community coordination: Collaborate across medical and social services.
Enhanced communication methods: Use secure messaging, email, and patient portals for engagement.
Patient data management: Identify care gaps and target interventions using population data.
Performance measurement: Track and report on quality, cost, and participation in programs like Merit-based Incentive Payment System (MIPS) or an Accountable Care Organization (ACO).

APCM vs CCM: What’s the difference?

Various Medicare care management programs have been designed to improve patient outcomes through consistent, ongoing support and with the intention to reduce costly hospitalizations and emergency room visits. Such programs include APCM and long-established Chronic Care Management (CCM), although there are some key differences in the programs:

Eligibility: APCM stratifies Medicare patients into three tiers based on medical complexity and socioeconomic factors. CCM, on the other hand, does not include patient stratification.
Billing model: CCM is billed monthly when at least 20 minutes of care coordination is provided. APCM instead offers a fixed monthly reimbursement based on the availability of comprehensive services, not time spent.
Care requirements: While CCM requires monthly outreach from a care manager, APCM allows flexibility. Care teams determine the right outreach frequency based on each patient’s needs.
Transitional care: APCM includes coordination during care transitions, such as after hospital discharge; while CCM care managers can assist with this, it is not a comprehensive service requirement.
Quality focus: APCM integrates quality measurement and reporting, placing a stronger emphasis on continuous improvement and outcomes compared to CCM.

When deciding which care management program to implement, healthcare providers should consider APCM as part of a larger care management solution based on patient needs. APCM is not designed to replace existing solutions but rather to help healthcare providers address care gaps proactively.

5 Reasons Health Providers Should Adopt APCM

With so many CMS programs available, it can be challenging for providers to determine which best fits their practice or patient population. Here are five key reasons why adopting Advanced Primary Care Management could be the right choice for your organization:

1. No Time Requirements

Many CMS programs require providers to meet time-based thresholds before they can bill for services. For example, the CCM program mandates at least 20 minutes of documented care coordination each month. APCM removes this barrier by basing reimbursement on patient risk stratification and service availability rather than time.

This approach allows providers to focus on delivering high-value, preventative care instead of tracking minutes. Care teams are given flexibility to tailor outreach and interventions to each patient’s needs. By measuring success through quality and outcomes rather than time spent, APCM better supports efficiency, patient engagement, and true value-based care.

2. Flexibility for Providers

Advanced Primary Care Management offers great flexibility for both patients and providers. Unlike other CMS programs with strict participation criteria, APCM broadens access and allows care teams to intervene earlier, especially for patients whose health risks don’t fit neatly into traditional billing categories. APCM is more flexible than other programs in that there is:

Broader eligibility: Patients can participate even without a diagnosed chronic illness, expanding access to vulnerable individuals.
No recent visit requirement: Patients aren’t required to have had a primary care visit within the past 12 months to qualify. Instead, they must have had a visit within 36 months
Customizable care approach: Providers have the freedom to adjust care frequency and intensity based on each patient’s current needs.

3. Use of Virtual Communication

Since Advanced Primary Care Management is a newer program, it supports the use of virtual communication technologies to help providers deliver continuous, patient-centered care beyond the traditional office visit. Through APCM, these virtual services can include:

Virtual check-ins for quick follow-ups and monitoring
Remote evaluations using pre-recorded patient information
Interprofessional consultations that connect care teams across specialties

By incorporating these tools and following secure healthcare IT practices, providers can offer a broader range of services tailored to each patient’s needs and bill through a simplified monthly bundle, rather than tracking individual services or minutes.

Additionally, virtual communication options also drive financial scalability and sustainability. When outreach, engagement, and documentation are managed remotely, organizations can serve more patients efficiently without increasing administrative burden.

4. Improve Quality Performance

APCM was just launched in 2025, so it will take time for data to be collected to measure the impact of the program on providers and patients alike. However, similar programs have seen improvement in quality performance while offering patients more comprehensive, reliable care.

For example, of the patients enrolled in ChartSpan CCM, 72% of them achieved well-controlled blood pressure according to CMS quality measures. This can likely be credited to the person-centered approach of CCM that helps patients manage their blood pressure through regular check-ins and educational information on hypertension. It can be expected that APCM will see similar success across quality measures impacting patients.

5. Streamline Billing

Surprisingly, administrative duties like updating the EHR are often more time intensive for healthcare staff compared to patient care. A study published in JAMA Network found that primary care providers spent an average of 36.2 minutes working in an EHR system per 30-minute visit, doing tasks such as charting, billing and coding.

APCM reduces the time spent updating administrative documentation by replacing the administrative burden of billing for every minute and individual service with a single monthly charge under the APCM code. Reducing the time spent on claims processing frees up providers and their staff to focus more on patient care and practice growth.

How to Implement APCM Easily With ChartSpan

Implementing a new CMS program may seem intimidating and time-consuming, but it doesn’t have to be that way when you use a solution like ChartSpan. Furthermore, the flexibility and patient benefits of Advanced Primary Care Management make the effort worth it for providers.

Check Your Resources

First you need to verify that you have the required resources for APCM implementation, or that you have a partner organization who does. These resources include:

Eligibility verification: Use the HIPAA Eligibility Transaction System (HETS) to confirm Medicare enrollment and QMB status.
Discharge notifications: Receive real-time alerts for hospital discharges to ensure timely transitional care.
Population health tools: Integrate clinical data from multiple sources to track outcomes and close care gaps.
24/7 care coordination: Maintain a dedicated team to manage urgent needs, update care plans, and ensure continuity between visits.
Referral networks: Build partnerships with community and home care organizations to address social determinants of health.
Medication management: Implement systems for medication reconciliation and adherence to reduce errors.
Analytics and reporting: Use ongoing data analysis to monitor quality metrics, improve performance, and meet APCM requirements.

Seamlessly Implement Advanced Primary Care Management

After you go through the above checklist, you’re ready to implement APCM at your practice or hospital. With ChartSpan, the implementation process is easy. Here’s how it’s done:

1. Onboarding and Workflow Setup

ChartSpan supports practices through a structured onboarding process that includes workflow customization, system integration, and staff training on APCM requirements. The process is designed to align with your existing operations and minimize disruption during setup.

2. Patient Identification and Enrollment

Next, through access to the HIPAA Eligibility Transaction System (HETS), ChartSpan helps identify patients who meet APCM criteria and determines their appropriate risk levels. After your team reviews the eligible patient list, ChartSpan manages outreach, obtains consent, and completes enrollment.

3. Ongoing Patient Engagement

ChartSpan’s care team maintains consistent communication with patients through regular check-ins, 24/7 care line access, educational support, and care plan updates, helping your practice or hospital meet the requirements for APCM. This structure promotes continuous patient engagement while reducing administrative responsibilities for in-house staff.

4. Proactive Interventions

Care managers monitor patient data and transitions to identify when additional support is needed, such as after a hospital discharge or when addressing care gaps. ChartSpan coordinates with your team to ensure timely follow-up and continuity of care.

5. Quality Measurement and Reporting

ChartSpan tracks performance metrics and provides reports to help practices assess outcomes and meet CMS quality standards. For Merit-based Incentive Payment System (MIPS)-participating practices or practices in Accountable Care Organizations (ACOs), ChartSpan assists with maintaining compliance through ongoing quality reporting.

6. Billing and Reimbursement Support

Using RapidBill technology, ChartSpan streamlines monthly billing and documentation. The system helps ensure accurate coding and reimbursement based on APCM levels while reducing manual administrative tasks for staff.

Improve Your Patient Care With APCM

Advanced Primary Care Management empowers providers to deliver preventive, patient-centered care while reducing administrative burden. Work with VHHA Solutions to connect with a reliable partner so your organization can implement APCM efficiently and improve outcomes, streamline operations, and build a more sustainable model of primary care.