Brilliant Care | Advanced Primary Care Management

Advanced Primary Care Management (APCM) is an evolution of chronic care management that expands proactive care to a broader patient population, including those with fewer or no chronic conditions, by stratifying care intensity to patient need. It’s sometimes called Primary Care Case Management or Population Health Management – essentially, providing personalized, preventive support to all your Medicare patients between office visits, not just the ones in traditional CCM programs. Brilliant Care’s APCM program is designed to help practices deliver this higher level of service across their entire panel, improving care continuity and capturing additional value-based revenue.

Key aspects of our APCM program:

Risk Stratification

We stratify your patient panel into risk tiers (often three levels) based on factors like number of chronic conditions, recent hospitalizations, social needs, and more. For example:

Level 1: Lower risk (0-1 chronic condition) – these patients still benefit from outreach, but perhaps quarterly check-ins or wellness coaching.
Level 2: Moderate risk (2+ chronic conditions) – similar to CCM, monthly outreach focusing on managing conditions.
Level 3: High risk (multiple conditions plus other risk factors like recent discharge or limited resources) – more intensive follow-up, perhaps biweekly calls and coordination with complex care resources.

Stratifying ensures we adapt care to patients’ health needs. High-risk patients get more frequent contact and support, whereas lower-risk patients receive lighter touch preventative check-ins. This efficient allocation of resources maximizes impact.

Preventive Focus

Even relatively healthy patients benefit from APCM through preventive care engagement. We conduct Health Risk Assessments, ensure they complete annual screenings, address lifestyle factors, and build a relationship so they reach out if health issues arise. It’s like giving every patient a care navigator who’s looking out for them. In fact, every Medicare patient can have a care manager under APCM, not just those with 2+ chronic conditions – which is great for prevention and early intervention.

Transitions of Care

A critical element is support during care transitions (e.g., a patient going from hospital back home). We offer support when patients transition between healthcare settings – a vulnerable time for lapses in care. Our team will follow up within 48 hours of discharge, reconcile medications, ensure home services are in place, and schedule timely follow-ups with PCP or specialists. This prevents readmissions and confusion.

24/7

Just like in CCM, APCM patients must have access to a 24/7 care line. This on-demand aspect keeps patients out of the ER unnecessarily and provides tremendous reassurance.

SDOH

A hallmark of APCM is addressing social determinants of health (SDOH) more robustly. Our care managers help connect patients to community resources for needs like transportation, food, housing, or help with utilities. For instance, if a patient isn’t taking their meds because they can’t afford them, or missing appointments because they lack a ride, we identify that and find a solution (e.g., liaising with charitable programs, arranging a ride service, etc.). This holistic approach treats the patient as a whole person, not just a set of medical conditions.

Recurring Value

CMS has introduced new codes (like Principal Care Management, etc.) and alternative payment models to support this broader management. Our program helps practices tap into those. For example, through APCM, practices might bill for managing even patients with 1 chronic condition (PCM codes) or get enhanced payments in value-based contracts for hitting quality measures. The bottom line APCM with Brilliant Care improves patient outcomes without overwhelming your staff.

Our process to implement APCM is straightforward. We handle the heavy lifting:

Onboard

We train your staff on the program and how it works (so they can explain it to patients as needed).

Identify & Enroll

Using data analysis, we identify eligible patients in each level; you approve the list, and we begin outreach to enroll them.

Engage

Our team engages patients regularly (frequency depending on level) to build those stronger patient connections through remote care. We keep patients continuously supported with check-ins, education, and by being available when needs arise.

Intervene

We intervene on care gaps or issues – whether it’s scheduling an AWV, addressing a spike in blood pressure, or coordinating a specialist referral.

Measure

We track everything – quality measures hit, hospitalizations prevented, patient satisfaction – and share these performance metrics with you.

Bill

We ensure all billing is done correctly for providing this advanced care.

In essence, APCM is about providing personalized care between office visits for all your Medicare patients. It elevates the standard of primary care, shifting it from reactive sick visits to proactive health partnership. Brilliant Care’s APCM offering allows you to achieve this model without overburdening your practice. We provide the people and process to make it work, and integrate seamlessly so it feels to the patient like it’s all coming from your office.

By adopting APCM, you can expand care to every patient and not just react to those who come in or call in crisis. You strengthen patient relationships, improve health outcomes and target care gaps (e.g., immunizations, cancer screenings) systematically. In value-based care environments, this is hugely advantageous for hitting targets and shared savings.

Think of APCM as the umbrella that covers your whole patient population, under which programs like CCM, RPM, and AWVs all coordinate. Brilliant Care is ready to deploy this comprehensive solution with you. We’ll handle the details; you’ll see the results in healthier, happier patients and a more successful practice.