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.

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