Table 1.

List of Non-Billable and Non-Visit-Based Care and Services (Care STEPs) for Documentation in Oregon’s APCM Community Health Centers

New Visit Types
 Home visit (billable encounter)
 Home visit (non-billable encounter)
 Online portal engagement*
 Advanced technology interactions*
 Health and wellness call
Patient Care Coordination and Integration
 Clinical follow-up and transitions in care setting
 Coordinating dental care
 Warm hand-off
 Behavioral health and functional ability screenings*
Education, Wellness, and Health Promotion
 Care gap outreach*
 Health education supportive counseling
 Education provided in group setting
 Support group participation
 Exercise class participation
Reducing Barriers to Health
 Case management
 Transportation assistance
 Accessing community resource/service
 Social determinants of health screening (integrated in 2017)
  • Care STEPs, care and services that engage patients; APCM, Alternative Payment and Advanced Care Model.

  • * Indicates that there was a standardized way for capturing in the electronic health record before APCM implementation.