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

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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

Key Takeaways (for on-air recap & social)

• Presence prevents: Being in the building daily beats any remote administrative stack.
• Rituals > heroics: Small, repeatable actions (exercise + vitals + lunch checks) compound.
• Caregivers stabilize: A modest weekly schedule creates 40 hours of reliable on-site support.
• Therapy cadence matters: Spread the care; keep people moving longer to reduce falls.
• Document to decide: Specific behavioral notes → faster NP decisions → fewer crises.
• Mission creates growth: Aligning to “no hospitalizations” reduces noise and increases referrals.

www.YourHealth.Org

Why transitional care is at the heart of Your Health’s model

How incentives for early post-hospital visits worked (and why they didn’t)

Why in-person care matters more than telehealth alone

The growing role of respiratory therapists, physical and occupational therapists, and community health workers

The challenge of patient perception: “too many visits” vs. “too many calls”

Why insurance companies trying to become providers is dangerous for patients

Scott’s philosophy: nothing should be written in stone — adapt and evolve

The simple but powerful call to action for providers: “Go see your damn patients.”

www.YourHealth.Org

Key Topics:

• How sudden insurance and policy changes disrupt patients and providers
• The importance of prevention and primary care in lowering long-term costs
• What fully staffed care teams look like and why they matter
• Balancing productivity and patient-centered care
• Why disruption is necessary for a healthier future
• Takeaway: Healthcare continues to be shaped more by profit and red tape than by prevention and patient outcomes. But with innovative care models and a relentless focus on what patients truly need, leaders can shift the system toward better health and lower costs.

www.YourHealth.Org

• What Health Connectors are and why they matter.
• The danger of a provider-centered workflow—and how to avoid it.
• Real examples of how proactive home visits catch problems early.
• Why vital signs can be the key to preventing 50% of heart attacks.
• The culture shift needed: salaried roles with responsibility, not clock-in/clock-out mindsets.
• Scott’s challenge to all healthcare workers: “Go see your damn patients.”

www.YourHealth.Org

• Scott shares a story about meeting a compliance pharmacist who unexpectedly became the solution to a major organizational challenge.
• The importance of pharmacy compliance and direct-to-manufacturer drug purchasing.
• Why God’s timing plays a role in healthcare growth and leadership decisions.
• The danger of miscommunication across facilities and how to “season” a team for long-term effectiveness.
• How leaders can emerge from any position — from providers to CNAs to medical assistants.
• Why job descriptions must be clear, but leadership requires flexibility.

www.YourHealth.Org