Advanced Primary Care Management (APCM) represents one of the more meaningful changes in the CMS Physician Fee Schedule. As of January 1, 2025, practices that adopt this model will be reimbursed through monthly, risk-stratified codes rather than only episodic, time-based billing. The intent is clear: create a predictable revenue stream while encouraging practices to focus on patient continuity and proactive management. For practices that are well-prepared, the opportunity is significant. Yet APCM comes with conditions, and the most challenging among them is the requirement for effective coordination of care transitions. This is where many programs falter, and where CMS scrutiny tends to be sharpest.
The Requirement in Plain Terms
Care transitions are moments of vulnerability for patients. Moving from a hospital stay back home, transferring into or out of a skilled nursing facility, or even navigating the aftermath of an emergency department visit all represent points where information can be lost, instructions misunderstood, or care delayed. CMS recognizes these risks, which is why APCM explicitly requires practices to coordinate across providers and settings, ensure timely exchange of health information, and follow up directly with patients or caregivers, typically within seven days of discharge or sooner if the situation warrants.
The policy may sound straightforward, but the operational burden is heavy. A practice must demonstrate that it can receive information when a patient is discharged, act on that information promptly, and document the steps taken to close the loop. It is not enough to have good intentions or informal processes. The expectation is that the system is reliable, repeatable, and visible in the record.
Why Practices Struggle
The biggest obstacle lies in awareness. If a practice never learns that a patient has been discharged, follow-up is impossible. Hospitals and emergency departments are not always equipped or incentivized to send notifications quickly, and health information exchanges remain inconsistent across regions. Even when the data flows, responsibility can be unclear. In too many organizations, no one is explicitly accountable for acting on alerts, reconciling medications, or scheduling the follow-up visit.
Technology limitations compound the problem. Many EHRs do not automatically generate discharge alerts or lack integrations to pull summaries from external providers. Staff then rely on manual tracking, which is prone to delay. Documentation gaps are also common. Practices may contact patients within the seven-day window but fail to record the communication or note the review of discharge instructions. In the eyes of CMS, if it is not documented, it did not happen. Finally, resource constraints matter. Care transitions occur at all hours, not just during clinic time. Without after-hours coverage or weekend planning, patients can slip through the cracks.
What Compliance Really Looks Like
Satisfying the care transitions requirement is less about heroic effort and more about building dependable infrastructure. A well-prepared practice has a mechanism in place to learn about discharges within 24 to 48 hours. It has a designated individual (often a care manager or transitions nurse) whose explicit role is to act on these alerts. That person ensures the discharge summary is obtained, medications are reconciled, and the patient or caregiver receives a call within the seven-day window.
Just as importantly, every step is documented. The EHR shows the date the summary was received, the content of the follow-up call, and the updates made to the care plan. Over time, the practice can demonstrate that the vast majority of transitions are handled in this structured way, with only well-documented exceptions when clinical judgment dictated otherwise. This is the level of consistency CMS expects, and it is also the level that reduces readmissions, improves patient satisfaction, and builds trust with partner providers.
How to Build Toward Readiness
Most organizations will need three to six months to implement this element reliably. The first step is to assess the current baseline: how often are discharges identified, and how often is follow-up documented within seven days? From there, leadership should designate clear ownership. Care transitions cannot be a side responsibility; they require explicit accountability.
Technology improvements come next. EHRs should be configured for alerts, and connections to health information exchanges or hospital systems should be activated wherever possible. Templates can make documentation faster and more uniform. Once processes are designed, staff training is essential. Everyone must understand their role and the expected turnaround times. Piloting the workflow with a subset of patients allows the team to troubleshoot before scaling to the entire panel.
Finally, monitoring and feedback close the loop. Practices that succeed are those that treat transitions as a continuous process rather than a one-time fix. Internal audits, regular reviews of documentation quality, and ongoing adjustments ensure that the system holds up under real-world pressure.
Common Pitfalls to Avoid
The most frequent mistake is misinterpreting “available” as “optional.” CMS does not expect every patient to receive every service element every month, but it does expect that the practice can deliver when clinically appropriate. Another pitfall is relying solely on the internal EHR. Patients often move across networks, and without external data feeds, a practice may remain blind to many discharges. Documentation is another trap. Oral or informal communications may improve patient care, but if they are not recorded in the chart, they carry no weight in compliance reviews. Lastly, organizations underestimate the strain on staff. Without dedicated resources, the workload piles on top of already full schedules, and consistency suffers.
The Strategic Payoff
When done right, coordination of care transitions pays dividends beyond APCM compliance. Patients experience smoother recoveries, unnecessary readmissions are reduced, and clinicians gain confidence that care plans are aligned. Hospitals and specialists see the practice as a reliable partner, strengthening referral relationships. And for practices pursuing value-based arrangements beyond APCM, these workflows form the foundation of cost containment and quality performance.
If your organization is preparing for APCM or already experimenting with it, now is the time to examine whether your care transition workflows can withstand CMS scrutiny. At Intelligence Factory, we offer a 20-minute readiness review focused on transitional care, technology tools, and documentation practices. We’ll benchmark your current state against best practices and develop a customized action plan to guide the next 90 days. Let’s connect.
Disclaimer: This post provides educational guidance only. Compliance, payment, and policy details vary by Medicare Administrative Contractor (MAC), local interpretation, and are subject to changing CMS rules.