KEY TAKEAWAYS

• The new ACO model increases funding for high-risk Medicare patients but requires disciplined execution.
• Visits — frequent, short, meaningful ones — are the #1 driver of reduced hospitalizations and better outcomes.
• The target is four visits per patient per month for those with a 2.4–2.8 risk score.
• Current numbers show only 2.5 visits per patient per month — leaving savings and outcomes on the table.
• Facilitators are essential: their job is to start conversations, gather information, and initiate telehealth visits.
• Notes, Mobius recordings, and consistent communication make providers more effective over time.
• Small, weekly touchpoints outperform long, infrequent visits in both outcomes and cost savings.
• Every team member plays a role in preventing hospitalizations and improving patient stability.

www.YourHealth.Org

00:00 – Welcome & Atlanta Traffic Humor
03:12 – Why Atlanta’s Senior Healthcare System Is “Almost Nonexistent”
09:15 – Hospitals begging for help & broken discharge processes
14:00 – Upcoming cuts to home health and rehab penalties
18:45 – Why therapy services need massive, immediate expansion
23:18 – The dementia support group story and the power of proactive care
30:52 – How storytelling improves patient and family understanding
36:44 – Hospice misconceptions & how Your Health does it differently
43:17 – Explosive growth in Atlanta and why competition is failing
49:10 – Creativity as a core ingredient of healthcare
54:40 – Why every associate needs a mentor immediately
59:25 – A call to action: show up, ride along, and support Atlanta providers

www.YourHealth.Org

Show Notes / Summary

• Why launch hospice now: continuity, fewer hospitalizations, value-based alignment
• Clarifying myths: CNA hours on hospice, attending provider still leads care
• RAF & staffing logic: ~$6k/mo hospice per diem ↔ RAF ~5; translating RAF → weekly CNA/CHW hours
• Nurse incentives: $150 per admission; double telehealth-assist credit on hospice patients
• Software + workflow: Athena ↔ WellSky (care plans, documentation, pull-through)
• Facility model: converting buildings; estimating FTEs from hospice census + RAF
• Chaplain/social work: leverage in-region LSWs; connect to patient’s faith community
• Respite options: Medicare respite/GIP + GUIDE program for dementia (up to $2,500yr)
• Therapy as palliative strength: weekly PTA/COTA; telehealth support
• After-hours model: optional call, $300 RN death/critical visit; $150 for non-nurse critical checks
• Guardrails: clinical judgment first; financials inform—not dictate—care

www.YourHealth.Org