APCM — Advanced Primary Care Management
Flags risk from care plans to Ava and Inbox. Billable APCM up, chart-chase down — consent, plan, and sign-off packaged so the program is turn-key.
The care loop
One continuous journey: chart export → gaps & sign-off → Ava between visits — and back again when the next CCD lands.
Upload a CCD and generate the provider and patient care plans in minutes — each one a versioned, auditable snapshot of the chart.
A care-gap checklist, chart-discrepancy review, consent tracking, and sign-off gates keep every plan complete before it's approved.
A warm voice between visits. Ava checks in with your patients by phone and SMS, and brings your team in when it matters.
Under the hood
Ava never gives medical advice. Agents follow your care plans, escalate to your team, and log every interaction for review.
FHIR-native integration and portable CCD chart exports — the workflow meets your EHR where it is, not the other way around.
Approval gates, audit trails, and versioned snapshots on every care plan. Documentation holds up when it's examined.
How a month unfolds
A CCD from your EHR — one file per patient, or a bulk archive for the whole panel. Patient identity comes from the chart itself.
The portal surfaces missing goals, unreviewed conflicts between sources, and consent status — with AI drafts you approve, never auto-applied.
Sign off to lock the snapshot, export the provider and patient PDFs, and release the plan to Ava.
Voice and SMS check-ins keep patients connected to the plan — and your team informed — until the next chart export starts the cycle again.
Talk to us about your Medicare panel and see the care-plan workflow on your own charts.