AH

ACUITYhealth

Home Health Proof of Concept

Passive Ambient Charge Capture for Skilled Care Teams

Transform every home visit, care coordination call, and patient interaction into captured value through ambient intelligence—enabling skilled care teams to focus on patient care while automatically documenting billable activities for value-based care readiness.

100%

Charge Capture

Zero

Manual Entry

85%

Time Saved

1

Home Health Team Operating Model

Provider-Supervised Skilled Care Coordination

Team Structure: One supervising provider (MD/NP) oversees 5-10 skilled care team members (RNs, LPNs, PTs, OTs, SLPs, HHAs) conducting home visits. All clinical interactions are passively captured through ambient recording, automatically mapped to appropriate charge codes, and attributed to the supervising provider for maximum reimbursement.

Provider (MD/NP)
Supervises Team

→

Skilled Care Team
5-10 Clinicians

→

Home Visits
300+ Patients

→

Value Capture
$3,600/Patient/Year

1:10

Provider to Staff Ratio

300+

Patients per Team

6-8

Daily Visits per Clinician

100%

Charge Capture Rate

Team Model Benefits

Provider reviews and attests to all team activities in 5-minute batches
Skilled care team focuses solely on patient care—zero documentation
Every home visit generates 20-60 minutes of billable time
Ambient capture includes OASIS assessments and care coordination
Practice manager reviews dashboards for ACO/VBC readiness

2

Home Visit Charge Capture Workflow

Passive Ambient Documentation During Skilled Care

How It Works: Clinician activates ambient recording upon entering patient home. Natural clinical conversation flows while AI captures every billable utterance. OASIS assessments, medication reviews, wound care, therapy sessions—all passively documented and mapped to appropriate charge codes in real-time.

Typical Home Visit Timeline

0-5 min
Arrival & Setup
Ambient Recording Starts

→

5-25 min
Clinical Care
Assessment & Treatment

→

25-35 min
Education
Family Engagement

→

35-40 min
Care Planning
Next Steps

What Gets Captured Automatically

OASIS Utterances
"Can you walk to the bathroom?" → Functional assessment

Medication Review
"Show me your pills" → Med reconciliation

Wound Assessment
"Let me check your dressing" → Wound care

Fall Risk
"Any dizziness lately?" → Safety evaluation

Pain Assessment
"Rate your pain 1-10" → Symptom management

Cognitive Screen
"What day is today?" → Mental status

Charge Capture Impact

40-minute visit = Multiple charge opportunities: Skilled nursing visit + CCM time + BHI screen + RPM review
Zero manual documentation: Clinician focuses entirely on patient care
Real-time charge validation: System confirms billable activities during visit
OASIS compliance: All required assessments captured naturally

3

Patient Engagement Between Visits

Digital Twin Health Companion

24/7 Patient Support: Between home visits, patients interact with their personalized digital health companion through phone, tablet, or smart speaker. Every interaction—whether checking symptoms, reviewing medications, or emotional support—generates billable engagement time while improving outcomes.

Daily Patient Touchpoints

Morning Check
"How did you sleep?"
PHQ-2 + Pain

→

Med Reminder
"Time for pills"
Adherence Track

→

Afternoon
"Any concerns?"
Symptom Monitor

→

Evening Wrap
"Daily goals met?"
Progress Track

4.2 min

Avg Daily Engagement

126 min

Monthly Billable Time

78%

Patient Participation

$150

Monthly Revenue/Patient

Engagement = Charge Capture

Morning mood check (2 min): Counts toward BHI (99484)
Medication confirmation (1 min): Counts toward CCM (99490)
Symptom review (1 min): Counts toward PCM (99426)
Vital signs prompt (30 sec): Counts toward RPM (99457)

Between-Visit Value Creation

Patient feels supported 24/7—not just during visits
Early detection of issues prevents readmissions
Every interaction automatically documented for charge capture
Provider reviews aggregated data in 2 minutes monthly

4

Multi-Level Charge Capture Architecture

Every Interaction Becomes Value

Comprehensive Capture: The platform simultaneously tracks billable activities across home visits, phone calls, digital engagement, and care coordination—aggregating time across all touchpoints to maximize legitimate reimbursement while maintaining compliance.

Charge Capture Sources

Home Visits
RN/PT/OT direct care
Skilled Visit + CCM/PCM

Phone Calls
Care coordination
CCM 99490

Digital Twin
Patient app engagement
BHI 99484

RPM Devices
BP cuff, glucometer
RPM 99457

Care Planning
Team conferences
CCM 99490

Family Calls
Caregiver education
CCM Add-on 99439

Monthly Charge Aggregation Example

Single Patient - 30 Days:

• 2 Home Visits (80 min) → Skilled nursing visits + 80 min toward CCM
• Digital Twin (126 min) → BHI (20 min) + CCM (60 min) + PCM (46 min)
• Care Coordination Calls (45 min) → CCM complex (99487)
• RPM Device Checks (20 min) → RPM (99457)
Total: $485 captured charges from routine care

Charge Capture Excellence

No billable minute goes uncaptured—100% documentation
Automatic code optimization selects highest-paying legitimate codes
Cross-functional time aggregation (visits + calls + digital)
Real-time threshold monitoring prevents under-billing

5

Daily Team Operations & Workflow

How Skilled Care Teams Work With Ambient Capture

Typical Day: Each clinician conducts 6-8 home visits while the platform passively captures all clinical activities. Provider reviews aggregated team activities at day's end. Practice manager monitors real-time dashboards for quality metrics and VBC readiness.

Team Member Daily Flow

7:30 AM
Team Huddle
Review High-Risk

→

8 AM-12 PM
Morning Visits
3-4 Patients

→

12-1 PM
Lunch + Calls
Care Coordination

→

1-5 PM
Afternoon Visits
3-4 Patients

Provider Supervision Workflow

Morning (5 min): Review overnight alerts from digital twin interactions
Midday (5 min): Scan real-time visit summaries from field team
End of Day (10 min): Batch attestation of team activities
Weekly (30 min): Quality review with practice manager

Practice Manager Dashboard Views

Team Productivity
Visits completed, time captured

Quality Metrics
HEDIS gaps, Star measures

Revenue Pipeline
Charges captured, claims ready

Patient Risk
CHI scores, readmission risk

VBC Performance
ACO metrics, cost trends

Compliance Status
Documentation, supervision logs

Operational Excellence

Clinicians save 2 hours daily on documentation
Provider manages 10x larger panel with less effort
Practice manager has real-time visibility for VBC contracts
100% audit-ready documentation with supervision trails

6

Value-Based Care & ACO Readiness

Metrics That Matter for Risk Contracts

VBC Foundation: Every home visit and patient interaction feeds real-time quality metrics, cost tracking, and outcome measurement—positioning your practice for success in ACO, bundled payments, and shared savings programs.

Key Performance Indicators

25%

Readmission Reduction

92%

HEDIS Measure Compliance

4.5

Star Rating Average

$4,800

PMPM Savings

18%

ED Utilization Decrease

98%

Quality Bonus Capture

ACO Success Metrics - Automatically Tracked

Preventive Care: Annual wellness visits, screenings, vaccinations
Chronic Disease Management: A1c control, BP management, med adherence
Care Coordination: Post-discharge follow-up, specialist communication
Patient Experience: CAHPS scores, engagement rates
Cost Efficiency: Admissions, readmissions, ED visits, total cost of care

How Ambient Capture Drives VBC Success

• Quality gaps close automatically through natural conversation capture
• Risk scores update continuously from home visit assessments
• Intervention effectiveness tracked through outcome correlation
• Total cost of care visible with predictive modeling
• Shared savings calculated in real-time dashboards

VBC Contract Advantages

Enter risk contracts confidently with proven metric tracking
Demonstrate value to payers with comprehensive data
Maximize quality bonuses through automated gap closure
Reduce total cost of care while improving outcomes

7

Practice & Nurse Manager Command Center

Real-Time Visibility Across All Operations

Manager View: Practice managers and nurse managers access unified dashboards showing team performance, quality metrics, financial pipelines, and payer-specific reporting—all updated in real-time from ambient capture data.

Nurse Manager Dashboard - Clinical Excellence

Staff Productivity
Visits, time, documentation

Clinical Quality
Wound healing, fall rates

Patient Acuity
CHI scores, risk stratification

Care Coordination
Handoffs, team communication

Compliance Tracking
OASIS, supervision, training

Staff Development
Skills gaps, education needs

Practice Manager Dashboard - Business Performance

Revenue Cycle
Charges, claims, payments

Payer Mix
Medicare, MA, commercial

Contract Performance
VBC metrics, shared savings

Operational KPIs
Cost per visit, margins

Growth Metrics
Referrals, census, retention

Payer Scorecards
Quality, utilization, cost

Payer-Specific Reporting (Auto-Generated)

Medicare: OASIS accuracy, Star ratings, HCC capture
Medicare Advantage: HEDIS gaps, risk adjustment, quality bonuses
Commercial: Network adequacy, cost trends, outcome metrics
ACO: Attribution, total cost of care, quality performance

Management Excellence Through Data

Managers see exactly where the team stands on all metrics
Predictive analytics highlight risks before they become issues
One-click reports for payer meetings and contract negotiations
Real-time alerts for quality gaps or compliance concerns

8

Revenue Generation & Financial Impact

How Charge Capture Drives Sustainable Growth

Revenue Model: Each patient generates $300/month through captured care coordination, engagement, and monitoring activities. With 300 patients per team, that's $90,000 monthly or $1.08M annually in previously uncaptured revenue.

Revenue Per Patient Breakdown

$113

CCM (99490)

$84

PCM (99426)

$71

BHI (99484)

$64

RPM (99457)

Team Economics (300 Patients)

Monthly Revenue Generation:

• Base home visit revenue: $45,000 (existing)
• + NEW care coordination capture: $33,900
• + NEW digital engagement: $21,300
• + NEW RPM monitoring: $19,200
• Quality bonuses: $12,000
Total Monthly: $131,400 (3x increase)

Investment & ROI

Platform Cost: $50 per patient per month
Net New Revenue: $250+ per patient per month
ROI: 500% in first year
Payback Period: 45 days
3-Year Value: $2.7M net revenue per team

Financial Transformation

Transform home health from cost center to profit center
Capture 100% of legitimate billable activities
Scale revenue without adding clinical staff
Position for value-based contract success

9

90-Day Implementation Roadmap

From Pilot to Full Deployment

Phased Approach: Start with 10-patient pilot, validate charge capture, scale to full panel. Zero disruption to current operations while building new revenue streams.

Phase 1: Days 1-30 (Pilot Launch)

Week 1
Team Training
Platform Setup

→

Week 2
10 Patient Pilot
Test Workflows

→

Week 3
Refine Process
Staff Feedback

→

Week 4
Validate Capture
Review Metrics

Phase 2: Days 31-60 (Scale & Optimize)

Expand to 50 patients across different acuity levels
Activate digital twin for patient engagement
Train all team members on ambient capture
Submit first claims for new charge codes
Manager dashboard training for practice/nurse managers

Phase 3: Days 61-90 (Full Deployment)

Scale to 300 patients full panel
Optimize workflows based on team feedback
Validate revenue capture with first payments
VBC readiness assessment with payer metrics
Prepare for ACO participation with quality data

4 hrs

Total Training per Staff

Day 30

First Charges Captured

Day 60

First Revenue Received

Day 90

Full ROI Validation

Implementation Success Factors

No workflow disruption—ambient capture works in background
Immediate time savings motivate staff adoption
Early revenue wins build organizational buy-in
Continuous support ensures smooth scaling

10

Proof of Concept Success Metrics

Measurable Impact Across All Stakeholders

POC Validation: Within 90 days, demonstrate 3x revenue increase, 85% documentation time savings, 25% readmission reduction, and complete VBC readiness—proving the model for enterprise-wide scaling.

Financial Impact

$1.08M

Annual New Revenue

$3,600

Per Patient Per Year

500%

First Year ROI

45 days

Payback Period

Clinical & Operational Impact

85%

Documentation Time Saved

25%

Readmission Reduction

100%

Charge Capture Rate

4.5

Star Rating Achievement

Stakeholder Benefits Summary

Patients

• 24/7 digital health companion
• Better outcomes, fewer readmissions
• More time with clinicians (not paperwork)

Providers & Staff

• 2 hours saved daily on documentation
• 3x revenue without more work
• Focus on patient care, not paperwork

Organization & Payers

• Ready for value-based contracts
• Proven quality metrics improvement
• Reduced total cost of care

Proof of Concept Delivers

Transform Home Health Into a Value-Generating Powerhouse

Every visit captured. Every interaction documented. Every opportunity realized.
Ready for ACOs. Ready for value-based care. Ready for the future.

AH

Thank You

From the entire ACUITYhealth team, thank you for your interest in transforming healthcare delivery through our Comprehensive Care Platform.

Our Leadership Team

Srinivas Nimmagadda, M.D.

Founder, Chief Executive Officer

Jake Saunders, M.D.

Chief Medical Officer

Ricky Shinall, M.D. Ph.D.

Chief Science Officer

Grant Saunders

Chief Technology Officer

Brian Williams

Chief Operating Officer

Ready to transform your practice with the power of ambient AI?

Contact Us: srinivas@acuity.health

Predict Health. Empower Life.