Advanced Primary Care Management (APCM) is reshaping how healthcare is delivered by unifying preventive, chronic, and transitional care services into a coordinated, patient-centric model. At its core, APCM helps providers deliver proactive, longitudinal care—ensuring patients receive continuous support between visits. At TimeDoc Health, we are proud to lead this evolution in virtual care.
What is Advanced Primary Care Management?
APCM is a CMS initiative launching in 2025, offering a monthly bundled payment model that replaces separate billing for services like Chronic Care Management (CCM), Principal Care Management (PCM), Transitional Care Management (TCM), virtual check-ins, and interprofessional consultations. It simplifies documentation while supporting a broader patient population—including those with zero or one chronic condition—without time tracking requirements.
TimeDoc Health’s Proven APCM Delivery Model
With over 3 million hours of virtual care delivered, TimeDoc Health brings unmatched experience to the implementation and delivery of care management programs. Our scalable platform and care coordination services allow us to deliver over 1 million minutes of care coordination in a single month, having served more than 500,000 unique patients.
We deliver APCM through a fully integrated and compliant model that includes:
- Comprehensive Clinical Services: RNs and clinical staff provide telephonic assessments, medication reconciliation, care planning, and follow-up.
- Behavioral Health Integration: Screenings and coordination with LCSWs.
- Preventive and Chronic Disease Management: Reminders for screenings (mammograms, A1c), lifestyle counseling, and risk mitigation pathways.
- Technology and Data: EMR-integrated platforms, real-time dashboards, and performance reporting.
Patient Stratification and Service Levels
TimeDoc Health utilizes intelligent risk stratification and population health analytics to assign patients to one of three tiers of care, each designed to meet patients where they are in their health journey. As part of our commitment to innovation, our platform leverages AI-driven insights that enhance care coordination, optimize resource allocation, and support success in value-based care models.
- GPCM1 – Low-Risk Population:
Focus: Preventive care adherence and health literacy.
Metrics: BCS, COL, CBP, LDL, A1c.
- GPCM2 – Rising Risk / Moderately Complex:
Focus: Stabilize chronic conditions and avoid exacerbations.
Metrics: SUPD, A1c Control, Diabetes Eye Exams, BP Control.
- GPCM3 – High-Risk / QMB Population:
Focus: Enhance quality of life, reduce admissions, support palliative care.
Metrics: Heart Failure Management, CKD, Polypharmacy, Readmission Reduction.
Clinical and Quality Alignment
Our APCM model supports key quality frameworks, including:
- Star Ratings: A1c control, blood pressure control, medication adherence.
- ACO Measures: ED and hospitalization rates, transitions of care.
- MA Plan Incentives: Preventive screening adherence and patient experience scores.
- Risk Coding Accuracy: Improved through structured documentation and care plan updates.
Operational Excellence and Compliance
We ensure a seamless APCM rollout with:
- Provider training and onboarding
- CPT tracking and audit-ready documentation
- Ongoing monthly optimization and performance reporting
Why Choose TimeDoc Health for APCM
We don’t just support APCM—we built a turnkey model designed for scalability, compliance, and results. From small practices to large health systems, our white-label or co-branded solutions make APCM implementation frictionless. With regulatory expertise, real-world ROI models, and direct clinical delivery under your brand, we are the trusted partner to operationalize APCM in 2025 and beyond.
Advanced Primary Care Management represents a significant step forward in Medicare care coordination. With simplified billing, broader eligibility, and outcome-focused delivery, APCM aligns perfectly with TimeDoc Health’s mission: to create patient success stories by improving the quality of life for those with chronic conditions.
Contact Us today to explore how our APCM solutions can enhance your practice.
