Operational Outcomes
- Earlier risk detection outside visit windows
- Fewer “unknowns” between check-ins
- Better patient engagement without added staff time
Financial & Program Impact
- Supports higher sustained enrollment
- Improves documentation quality and continuity
- Reduces staff follow-up overhead per patient
Where This Fits
- Complements existing ACP workflows
- No replacement of clinical decision-making
- No billing interference or code dependency
Designed to strengthen programs already billing CMS-supported care management codes.
Who This Helps Most
- Clinical Teams: Goals of care conversations with documented patient preferences—proactive, not reactive.
- Operations: Structured ACP workflow integrated with AWV and CCM—no separate process required.
- Leadership: Billable ACP events plus better alignment with patient values at end of life.