How to Create a Patient-Centered Care Plan for CCM and APCM: A Step-by-Step Guide

Topics

Key takeaways

A patient-centered care plan organizes a patient's conditions, goals, and interventions around the patient's own priorities as well as clinical targets.
Chronic care management (CCM) and advanced primary care management (APCM) both require an electronic comprehensive care plan that the full care team can access.
CMS lists 12 elements a care plan may include, from a problem list and measurable goals to caregiver assessment and periodic review.
Goals the patient helps define, written in measurable terms, give every check-in something specific to track.

A well-built patient-centered care plan keeps every clinician working from the same view of the patient and gives each care management interaction a clear purpose. For organizations running chronic care management (CCM) or advanced primary care management (APCM), it is also a billing requirement: Medicare pays for neither program without one.

What Is a Patient-Centered Care Plan?

A patient-centered care plan is an individualized electronic record, maintained by the care team, of a patient's chronic conditions, treatment goals, planned interventions, and the people and resources involved in their care. A treatment plan typically addresses one condition from the clinician's point of view. A patient-centered care plan covers all of the patient's conditions and sets goals with the patient, based on what matters to them, such as staying independent at home, avoiding another hospital stay, or controlling pain well enough to keep working.

Why Is a Care Plan Required for CCM and APCM?

Both programs require a comprehensive care plan because care management between visits depends on one shared document. Every CCM patient has at least two chronic conditions, and many APCM patients do too, often with several specialists involved. The care plan gives primary care, specialists, and care managers a single picture of the patient's health.

The plan also ties clinical targets to the patient's life. A blood pressure goal means something different for a patient trying to stay independent at home than for one whose priority is avoiding readmission. Recording that context lets the care team direct support toward the outcomes the patient cares most about.

Ongoing care management takes its structure from the plan as well. CCM is billed on monthly clinical staff or practitioner time, which goes largely to reviewing goals, managing medications, and updating the plan. APCM has no time requirement, but the plan still guides regular contact focused on the patient's main concerns.

What Should a Care Plan Include?

The chronic care management booklet developed by CMS lists the elements a comprehensive care plan may include. APCM requires an electronic patient-centered comprehensive care plan as one of its service elements, but CMS's APCM guidance doesn't enumerate care plan contents the way the CCM booklet does, so the CCM elements work as a practical checklist for both programs. The plan doesn't need every element updated every month, but it should address each one that applies.

Care Plan Element	Where It's Covered
Cognitive and functional assessment	Step 1
Problem list	Step 2
Measurable treatment goals	Step 3
Expected outcome and prognosis	Step 4
Symptom management	Step 5
Planned interventions	Step 5
Medical management	Step 5
Environmental evaluation	Step 6
Caregiver assessment	Step 6
Interaction and coordination with outside resources and practitioners	Step 7
Periodic review	Step 8
Revision and monitoring, when necessary	Step 8

How to Create a Patient-Centered Care Plan in 8 Steps

The care team builds the first version of the plan at enrollment, once the patient has consented and any required initiating visit is complete. The same steps guide each later revision.

Step 1: Complete a Comprehensive Assessment

Building a care plan starts with an assessment of the patient's physical, mental, cognitive, functional, psychosocial, and environmental status. Pull from the EHR, recent visit notes, medication lists, lab results, and remote patient monitoring readings where available. The cognitive and functional review from a recent annual wellness visit (AWV) is a useful starting point.

Step 2: Build the Problem List With the Patient

List the chronic conditions and active issues, then ask what each one means for the patient's daily life. A patient with COPD and diabetes may care less about an A1c target than about walking to the mailbox without getting winded.

Step 3: Set Measurable Goals the Patient Helped Define

Care plan goals work best when the patient agrees with them and they follow the SMART framework: specific, measurable, achievable, relevant, and time-bound. A goal such as "walk 10 minutes a day, five days a week, by the end of next month" gives the care team something specific to check at each interaction.

Step 4: Document Expected Outcomes and Prognosis

For each condition, note what should improve, what will be managed long term, and which changes would signal a decline that needs escalation. A shared view of the likely course helps the care team and patient set expectations together.

Step 5: Plan Interventions, Symptom Management, and Medications

The interventions section of a care plan spells out what the team will do: medication changes, referrals, self-management education, symptom management, and monitoring frequency. Reconcile the medication list against what the patient reports actually taking, and flag adherence or interaction concerns.

Step 6: Assess the Home Environment and Caregiver Support

Factors outside the exam room, such as the patient's living situation, transportation, food access, and who helps with daily care, decide whether a plan works at home. When a caregiver is involved, assess what that person can handle and what support they need.

Step 7: Coordinate With Outside Practitioners and Community Resources

A care plan should record how it is shared with specialists, home- and community-based service providers, and facilities involved in the patient's care. Note how the team follows up after emergency department visits and discharges from hospitals or skilled nursing facilities, since both CCM and APCM include care transition management.

Step 8: Maintain and Share the Plan

Keep the plan electronic and make it available promptly to care team members inside and outside the billing practice. Set a review cadence, and revise the plan whenever the patient's condition, goals, or circumstances change.

What Does a Patient-Centered Care Plan Look Like?

The excerpt below shows how the eight steps discussed earlier come together for a hypothetical 72-year-old patient with COPD and type 2 diabetes who lives alone and gets help from her daughter twice a week.

Care Plan Element	Sample Entry
Cognitive and functional assessment	No cognitive impairment on her AWV screen; needs help with grocery shopping
Problem list	COPD; type 2 diabetes
Measurable treatment goals	Walk to the mailbox and back without stopping to rest within eight weeks; reach the A1c target set with her primary care physician by her next quarterly lab
Expected outcome and prognosis	COPD stable, with higher flare risk in winter; diabetes control expected to improve as medication adherence improves
Symptom management	Logs rescue inhaler use; calls the care manager if use increases or breathlessness worsens
Planned interventions	Pulmonary rehabilitation referral, diabetes self-management education, and a monthly care manager check-in
Medical management	Medication reconciliation found missed evening doses; physician to review the regimen at her next visit
Environmental evaluation	Lives alone in a second-floor apartment without a car; pharmacy delivery arranged
Caregiver assessment	Daughter visits twice a week, handles groceries, and wants help learning correct inhaler technique
Coordination with outside resources and practitioners	Pulmonologist receives each updated plan; care manager calls after any ED visit or discharge
Periodic review and revision	Reviewed at each monthly check-in; revised after the pulmonary rehabilitation intake assessment

What makes this plan patient-centered is how her priorities and circumstances shape each entry. Her goal of walking to the mailbox drives the pulmonary rehabilitation referral, and living alone without a car explains the pharmacy delivery. The missed evening doses and her daughter's request for inhaler training give the care manager specific items to follow up on at the next check-in.

CCM vs. APCM: Care Plan Requirements Compared

The care plan requirement is nearly identical across CCM and APCM programs, with small differences in access, patient copies, and the documentation surrounding the plan.

	CCM	APCM
Care plan requirement	Establish, implement, revise, or monitor a patient-centered electronic comprehensive care plan	Develop, implement, revise, and maintain an electronic patient-centered comprehensive care plan
Access	Available promptly inside and outside the billing practice	Available within and outside the billing practice, as appropriate, with routine care team access to update it
Copy for the patient or caregiver	Required	Required
Other documentation	Consent, an initiating visit for new patients or those not seen within a year, and time logs	Consent, an initiating visit for new patients or those not seen within three years, and the ability to deliver every service element

Common Care Plan Mistakes

Each of the following mistakes weakens the plan as a tool for patient care and makes it harder to show that the plan was established, revised, and shared as CMS requires.

Copied plans. A plan carried over from a template without changes doesn't reflect the individual patient's problems, goals, or circumstances.
No revision history. Even for a stable patient, a plan that never changes looks unmonitored.
Unused plans. Check-ins should reference the plan's goals and record what changed.
Limited access. Outside practitioners involved in the patient's care, and the patient where required, need to be able to see the latest version.

How Prevounce Supports Care Planning

Keeping an individualized plan up to date for every enrolled patient is difficult to sustain by hand as a program grows. Prevounce is a remote care management company that provides software, cellular-connected devices, and clinical services for CCM, APCM, and remote patient monitoring (RPM). Prevounce CCM software offers editable care plan templates that let care teams pick the items that fit each patient, and its APCM software serves up commonly used barriers and treatment goals to build from when customizing a plan. Embedded AI tools analyze historical patient data to deliver care summaries and recommendations.

Book a consultation to see how Prevounce helps care teams build and maintain care plans across CCM and APCM.

Frequently Asked Questions About CCM and APCM Care Plans

Is a care plan required to bill CCM and APCM?

Yes. CCM billing requires a comprehensive care plan that is established, implemented, revised, or monitored. APCM lists the care plan among its required service elements.

How often does a care plan need to be updated?

CMS doesn't set a fixed schedule. The plan needs periodic review and should be revised when something meaningful changes for the patient. Reviewing it during regular check-ins keeps it accurate.

Who creates the care plan?

The billing practitioner oversees the plan, and clinical staff such as nurses and care coordinators handle the assessment and documentation under that practitioner's supervision. The patient and, where relevant, the caregiver supply the priorities that make the plan patient-centered.

Does the patient get a copy of the care plan?

For APCM, yes. CMS requires giving the patient or caregiver a copy. For CCM, CMS says to provide a copy when necessary.

Can the same care plan be used for CCM and APCM?

Yes. Both programs call for an electronic patient-centered comprehensive care plan, and the CMS elements serve as a checklist for either. When a patient moves from CCM to APCM, document APCM consent and give the patient or caregiver a copy of the plan.

Disclaimer: This article is for informational purposes only and is not medical or clinical professional advice. It does not replace the judgment of a qualified healthcare professional. Decisions about a patient’s assessment, goals, interventions, and care plan should be made by the treating practitioner based on the patient’s individual circumstances.

Arun Chandra, MD

Arun Chandra, MD is the Clinical Lead of Prevounce. Dr. Chandra writes about clinical evidence in digital health, cardiology workflows, and the clinical implementation of chronic care services while working closely with Prevounce's teams to develop care protocols based on the latest clinical evidence and inform product and corporate strategy. He is also a practicing Internist and fellow in Cardiology at New York-Presbyterian Hospital and holds his medical degree from Johns Hopkins University School of Medicine. With particular interests in the use of cutting-edge healthcare technology, he is well-versed in the clinical applications of remote patient monitoring, chronic care management, and wellness services and their ability to improve patient outcomes.