Advanced Primary Care Management
for Providers
Clinii’s Advanced Primary Care Management model enables providers to proactively manage patient populations through preventive care, data analytics, and integrated coordination—delivering measurable improvements in quality, equity, and efficiency.
What Are Advanced Primary Care Management Services?
Advanced Primary Care Management (APCM) is a comprehensive, team-based approach to delivering primary care that emphasizes proactive, coordinated, and patient-centered services. It goes beyond traditional primary care by integrating population health strategies, data analytics, behavioral health,
care coordination, and social determinant interventions to improve health outcomes and reduce costs. APCM supports Value-Based Care models by focusing on preventive care, chronic disease management, and continuous quality improvement.
1. Strengthen Preventive Care Delivery
APCM emphasizes proactive, preventive care as a cornerstone of improved health outcomes. By identifying at-risk patients early and implementing evidence-based screenings and interventions, practices can reduce disease progression, avoid costly acute episodes, and increase patient engagement in long-term wellness.
2. Improve Care Coordination
Through structured care teams and clear workflows, APCM improves coordination between primary care providers, specialists, hospitals, and community organizations. This reduces fragmentation, ensures continuity of care, and helps patients navigate complex health systems more effectively—particularly those with chronic or comorbid conditions.
3. Align With Value-Based Payment Models
APCM supports the shift from volume-based to Value-Based Care by aligning clinical practices with quality metrics, cost reduction goals, and patient satisfaction benchmarks. Practices can participate in models like ACOs or PCMHs more effectively, positioning themselves for shared savings and performance-based incentives.
4. Leverage Data for Population Health Management
Data analytics is a vital tool within APCM, enabling teams to stratify risk, track outcomes, and identify care gaps at both the patient and population levels. Actionable insights support targeted outreach, improve care planning, and drive continuous quality improvement.
5. Address Social Determinants of Health (SDOH)
Integrating social determinant screening and interventions into primary care workflows helps address barriers such as housing insecurity, food access, and transportation. APCM encourages partnerships with community-based organizations, reinforcing whole-person care and reducing avoidable health disparities.
6. How Clinii Supports APCM Success
Clinii’s APCM solutions provide healthcare teams with integrated tools to operationalize advanced primary care. From SDOH screening and real-time analytics to care coordination workflows and community referral management, Clinii helps organizations implement APCM
at scale, improving efficiency, quality, and patient outcomes while meeting the demands of Value-Based Care.
HCPS G0558
Provider performs APCM services for one month for a Qualified Medicare Beneficiary (QMB) with two or more chronic conditions.
Frequently Asked Questions About Advanced Primary
Care Management
1. How often can you bill for APCM services?
You can bill for APCM services once per patient per calendar month. This helps remove some of the burden
of billing individual, time-based care management codes.
2. How does APCM differ from traditional primary care?
APCM goes beyond traditional, episodic primary care by adopting a comprehensive, team-based, and proactive model. While traditional care often focuses on treating illness as it arises, APCM emphasizes prevention, chronic disease management, care coordination, and population health. It incorporates data analytics, addresses SDOH, and aligns care delivery with value-based payment models, resulting in improved patient outcomes and more efficient use of healthcare resources.
3. Can small or independent practices implement APCM effectively?
Yes, small and independent practices can successfully implement APCM with the right support and scalable tools. APCM can be tailored to fit smaller settings by focusing on key components like care coordination, preventive outreach, and use of shared technology platforms.