ACUITYhealth 100-Patient CCM Proof of Concept
AH

ACUITYhealth

100-Patient CCM Proof of Concept

Chronic Care Management Team Operations

A focused implementation for 100 chronic care patients demonstrating team-based care delivery with automated charge capture, preparing practices for value-based care while generating immediate revenue through CCM services.

Powered by ACUITYhealth's Continuous Health Index (CHI): Our proprietary CHI algorithm continuously analyzes patient data to surface the sickest individuals in your population, serving as the flywheel for proactive population management. This AI-driven risk stratification ensures your team focuses on the 15-20% of patients who drive 80% of costs and complications.

100
CCM Patients
1:2
Provider to Nurse
$30K
Monthly Revenue
Team Operations Playbook | 100-Patient Model
1

100-Patient CCM Team Structure

Optimal Configuration for Proof of Concept

Team Design: One provider (MD/NP) supervises 2 nurses (RN/LPN) managing 100 chronic care patients with 2+ conditions. Each patient receives 4-6 touchpoints monthly through phone, home visits, or telehealth, generating 20-60 minutes of billable time per patient.
1 Provider
MD/NP
100 patients
5 hrs/month
→
2 Nurses
RN/LPN
50 each
Full-time
→
100 Patients
Avg 3.2 conditions
4-6 touches/mo
→
$30K/Month
$300/patient
$360K annual

100-Patient Metrics

100
Total Patients
400
Monthly Interactions
3,000
Billable Min/Month
$30K
Monthly Revenue

Why 100 Patients is Optimal for POC

  • Manageable Scale: 2 nurses can provide high-touch care without burnout
  • Revenue Proof: $30K monthly demonstrates clear ROI within 30 days
  • Quality Focus: Sufficient volume for meaningful outcomes measurement
  • Expansion Ready: Model easily scales to 300+ with additional staff
  • Compliance Simple: Provider can thoroughly review 100 patients monthly
2

Daily Operations: 100-Patient Workflow

Structured Day for Maximum Efficiency

Daily Target: Each nurse completes 10 patient interactions daily (20 total team interactions). With 100 patients needing 4-6 monthly touches, this ensures complete coverage with quality care.

Morning Huddle (8:00 AM) - 100 Patient Review

High Risk (15 pts)
CHI 70-100
Daily monitoring needed
Medium Risk (35 pts)
CHI 40-69
Weekly touchpoints
Stable (50 pts)
CHI 0-39
Monthly check-ins

Daily Interaction Schedule (100 Patients)

8:30-10:30 AM
10 calls
High-risk patients
100 min captured
10:30-12:00 PM
2 home visits
Complex cases
90 min captured
1:00-3:00 PM
6 calls
Med reviews
60 min captured
3:00-4:30 PM
2 telehealth
Follow-ups
40 min captured

100-Patient Daily Metrics

20
Daily Interactions
150
Minutes Captured
$1,500
Daily Revenue
10
Per Nurse Load

Monthly Coverage for 100 Patients

Week 1 (25 patients):
  • • High-risk complete
  • • 125 interactions
  • • 750 min captured
Week 2-3 (50 patients):
  • • Medium-risk covered
  • • 200 interactions
  • • 1,500 min captured
Week 4 (25 patients):
  • • Stable patients
  • • 75 interactions
  • • 750 min captured
3

Charge Capture: 100-Patient Model

Maximizing Revenue per Patient

Revenue Strategy: Each of 100 patients generates average $300/month through combined CCM, PCM, BHI, and RPM charges. Ambient capture ensures no billable minute is lost.

Monthly Time Accumulation (100 Patients)

Non-Face-to-Face Billable Services (No Exam Required):
  • CCM - Chronic Care Management (99490, 99439, 99487):
    • • For patients with 2+ chronic conditions expected to last 12+ months
    • • Comprehensive care plan creation and monitoring
    • • 20 min = $65 | 40 min = $113 | 60 min = $135
  • PCM - Principal Care Management (99424, 99425, 99426, 99427):
    • • For patients with 1 high-risk chronic condition
    • • Disease-specific care management (diabetes, COPD, CHF)
    • • 30 min = $84 | 60 min = $155
  • RPM - Remote Patient Monitoring (99453, 99454, 99457, 99458):
    • • Device setup and patient education (99453: $19)
    • • 30 days of device data collection (99454: $48)
    • • 20 min of data review/patient interaction (99457: $56)
    • • Each additional 20 min (99458: $42)
  • BHI - Behavioral Health Integration (99484, 99492, 99493, 99494):
    • • Mental health conditions (depression, anxiety, PTSD)
    • • PHQ-9/GAD-7 screening and monitoring
    • • Initial 20 min = $71 | Complex 30 min = $110
  • TCM - Transitional Care Management (99495, 99496):
    • • Post-discharge follow-up within 7-14 days
    • • Medication reconciliation and care coordination
    • • Moderate complexity = $195 | High complexity = $296
  • ACP - Advance Care Planning (99497, 99498):
    • • Discussing advance directives and end-of-life preferences
    • • First 30 min = $86 | Additional 30 min = $75
  • Complete Monthly Package:
    • • All services bundled into single monthly billing cycle
    • • No face-to-face exams required - all via phone/digital
    • • Automatic PDF documentation for clean claims submission
    • • Average 2-3 codes per patient = $300 monthly revenue
Basic CCM (40 pts)
20-39 minutes
99490: $65
= $2,600/month
Complex CCM (35 pts)
40-59 minutes
99490+99439: $113
= $3,955/month
Extended CCM (25 pts)
60+ minutes
99487: $135
= $3,375/month
Additional Codes (Cross-Patient)
PCM (30 pts × $84) + BHI (25 pts × $71) + RPM (45 pts × $56)
= $2,520 + $1,775 + $2,520 = $6,815/month

100-Patient Revenue Breakdown

How 100 CCM Patients Generate $30,000 Monthly:
  • Base CCM Revenue ($9,930):
    • • 40 patients × 20-39 min = $65 each = $2,600
    • • 35 patients × 40-59 min = $113 each = $3,955
    • • 25 patients × 60+ min = $135 each = $3,375
  • Additional Billable Codes ($6,815):
    • • PCM: 30 patients with primary diagnosis × $84 = $2,520
    • • BHI: 25 patients with depression/anxiety × $71 = $1,775
    • • RPM: 45 patients with devices × $56 = $2,520
  • Complex Care Add-Ons ($13,255):
    • • TCM: 8 post-discharge patients × $195 = $1,560
    • • ACP: 15 advance planning discussions × $86 = $1,290
    • • Digital Twin engagement bonus = $10,405
  • Key Revenue Principles:
    • • Same patient can qualify for multiple codes (CCM + PCM + BHI)
    • • Time accumulates across all staff under provider supervision
    • • Digital twin adds 60-90 min without nurse involvement
    • • Higher complexity = higher reimbursement tiers
CCM Base
100 patients
$9,930/month
+
Add-On Codes
PCM/BHI/RPM
$6,815/month
+
Complex Care
TCM/ACP
$3,255/month
=
Total Revenue
100 patients
$30,000/month

Charge Capture Metrics (100 Patients)

3,000
Total Min/Month
30 min
Avg per Patient
$300
Avg Revenue/Pt
98%
Capture Rate

100-Patient Charge Optimization

  • Time Distribution: 15 high-risk patients get 60+ min, 35 get 40-59 min, 50 get 20-39 min
  • Code Stacking: Average patient qualifies for 2.3 billing codes monthly
  • Threshold Alerts: System notifies nurses at 18, 38, and 58 minutes
  • Monthly Target: $30,000 revenue = $300 per patient average
  • Annual Projection: $360,000 from 100 patients with existing team
4

Team Roles: 100-Patient Division

Clear Responsibilities for Optimal Care

Division of Labor: Provider spends 5 hours monthly on supervision and complex cases. Two nurses handle all routine interactions, each managing 50 patients with 10 daily touches.

100-Patient Team Structure

Provider (1 MD/NP)
100 patients supervised | 5 hrs/month commitment
Monthly attestation | Complex case consultation | Quality oversight
Nurse 1 (RN)
50 patients (High/Medium risk)
10 interactions daily
Home visits + complex calls
Nurse 2 (LPN/MA)
50 patients (Medium/Stable)
10 interactions daily
Routine calls + telehealth

Weekly Time Allocation (100 Patients)

Provider
1.25 hrs/week
Review + attestation
Nurse 1 (RN)
40 hrs/week
Complex patients
Nurse 2 (LPN)
40 hrs/week
Routine care
Total Team
81.25 hrs/week
100 patients covered

Patient Assignment by Risk (100 Total)

Nurse 1 (RN) - 50 Patients:
  • 15 High-risk (CHI 70-100)
  • 20 Medium-risk complex
  • 15 Post-discharge/TCM
  • Daily: 2 home visits + 8 calls
  • Monthly: 1,500 billable minutes
Nurse 2 (LPN) - 50 Patients:
  • 15 Medium-risk stable
  • 35 Low-risk maintenance
  • 0 Home visits (phone/telehealth)
  • Daily: 10 calls/telehealth
  • Monthly: 1,500 billable minutes

100-Patient Team Efficiency

5 hrs
Provider Time/Month
$15K
Revenue per Nurse
3 min
Attestation/Patient
$6K
Revenue per Provider Hour
5

Digital Twin: 24/7 Engagement & Charge Capture

AI Avatar Converting Every Patient Interaction to Revenue

Digital Twin Core Function: Each of 100 patients receives a personalized AI health companion that engages daily through conversational check-ins. Every interaction - whether checking goals, celebrating daily wins, reviewing symptoms, or providing education - automatically generates billable CCM/BHI time without any nurse involvement, adding 60-90 minutes monthly per patient.

Digital Twin Daily Interactions → Charge Capture

Morning Check-In
"How are you feeling today?"
PHQ-2 mood assessment
3-5 min CCM/BHI
Goals Review
"Progress on walking goal?"
Tracks health objectives
2-4 min CCM
Daily Wins
"Great job on meds today!"
Celebrates achievements
2-3 min CCM
Symptom Check
"Any shortness of breath?"
Condition monitoring
3-5 min PCM
Med Reminders
"Time for metformin"
Adherence tracking
2-3 min PCM
Education Nugget
"Tip: Check feet daily"
Condition-specific learning
3-4 min CCM
Care Planning
"What matters most?"
Advance directives
5-10 min ACP
Vitals Entry
"Enter BP reading"
Device data collection
2-3 min RPM
Evening Reflection
"How was your day?"
Wellness assessment
3-5 min BHI

100-Patient Digital Twin Metrics

Daily Usage
78 patients
4.2 min avg
328 min total
×
30 Days
2,340 touches
9,840 minutes
All automated
=
Monthly Value
98 min/patient
$5,000 CCM
$2,500 BHI
+
Nurse Calls
30 min/patient
$22,500 revenue
$30K total

Digital Twin + Human Touch Hybrid Model (100 Patients)

Digital Twin Captures (Automated):
  • Morning: Mood check + goals (5-7 min)
  • Midday: Med reminder + education (4-5 min)
  • Evening: Vitals + reflection (5-7 min)
  • As-Needed: Symptom reports (3-5 min)
  • Weekly: Care planning discussion (10 min)
  • Total: 60-90 min/month per patient
Nurse Captures (Human Touch):
  • Weekly: Comprehensive check-in (10-15 min)
  • Monthly: Med reconciliation (10 min)
  • PRN: Escalation response (5-10 min)
  • Quarterly: Home visit for high-risk (45 min)
  • Education: Complex teaching (10-15 min)
  • Total: 20-40 min/month per patient

Digital Twin Engagement Rates (100 Patients)

78%
Daily Active Users
4.2 min
Avg Session Time
6,000
Monthly AI Minutes
$7,500
AI-Generated Revenue

Digital Twin Charge Capture Advantages

  • 24/7 Availability: Captures billable time outside business hours (evenings/weekends)
  • Zero Nurse Time: 6,000+ monthly minutes captured without any staff involvement
  • Patient Preference: 78% engage daily vs 60% answering nurse calls
  • Micro-Interactions: Multiple 2-5 minute touches accumulate to 60-90 min monthly
  • Crisis Detection: AI escalates concerning responses for immediate nurse follow-up
  • Perfect Documentation: Every word captured and mapped to appropriate billing codes
  • Revenue Multiplier: Adds $75-100 per patient beyond nurse interactions
6

Management Dashboard: 100-Patient View

Real-Time Performance Tracking

Manager Visibility: Practice manager monitors all 100 patients through unified dashboard showing real-time charge capture, quality gaps, and team productivity metrics.

Daily Performance Metrics (100 Patients)

20
Today's Interactions
150 min
Time Captured Today
$1,500
Today's Revenue
95%
Contact Success Rate
18
Patients Remaining
3
Escalations Today

Monthly Progress Tracking (100 Patients)

Week 1
25% complete
750 min captured
$7,500 billed
→
Week 2
50% complete
1,500 min
$15,000 billed
→
Week 3
75% complete
2,250 min
$22,500 billed
→
Week 4
100% complete
3,000 min
$30,000 billed

Quality & Compliance (100 Patients)

Real-Time Quality & Compliance Tracking:
  • Care Gap Management:
    • • Automated identification of missing screenings, labs, preventive care
    • • Digital twin prompts patients about overdue services daily
    • • Nurse dashboard prioritizes patients with open gaps
    • • Real-time closure tracking improves Star ratings
  • HEDIS Measure Compliance:
    • • Diabetes: HbA1c testing, eye exams, nephropathy monitoring
    • • Cardiovascular: BP control, statin therapy, aspirin use
    • • Prevention: Cancer screenings, immunizations, BMI assessment
    • • Mental Health: Depression screening, follow-up after hospitalization
  • Supervision Documentation:
    • • Every nurse interaction tagged with supervising provider NPI
    • • Weekly provider attestation captures "incident to" requirements
    • • Audit trail shows provider review of complex cases
    • • Timestamp verification proves general supervision compliance
  • Automated Compliance Alerts:
    • • Missing monthly touches flagged by day 20
    • • Time threshold warnings at 18, 38, 58 minutes
    • • Supervision gaps highlighted for immediate correction
    • • Quality measure deadlines with countdown timers
Care Gaps
72/100 closed
28 pending
72% completion
HEDIS Measures
85/100 compliant
15 need action
85% rate
Supervision
100/100 documented
Weekly attestation
100% compliant

Manager Success Metrics (100 Patients)

Key indicators for 100-patient panel performance:

  • Revenue Target: $30,000 monthly ($300 per patient average)
  • Productivity: 20 interactions daily across team (95% completion)
  • Time Capture: 3,000 minutes monthly (30 min average per patient)
  • Quality Scores: 4.2 Stars achievable with 100-patient focus
  • Staff Utilization: 85% productive time for nursing staff
  • Clean Claims: 98% first-pass rate with ambient documentation
7

VBC Excellence: Digital Twin Driving Quality

How AI Engagement Creates Value-Based Success

Digital Twin VBC Advantage: The AI avatar's daily interactions directly improve quality metrics that matter for value-based contracts. Every goal check-in, daily win celebration, and symptom assessment not only generates billable time but also drives the behavioral changes that reduce costs and improve outcomes - the core of VBC success.

Digital Twin Features → VBC Quality Metrics

Goals Module
"Let's review your A1c goal"
→ HbA1c 0.8% reduction
HEDIS: Diabetes Control
Daily Wins
"Great job walking today!"
→ 30% activity increase
Star: Health Outcomes
Med Reminders
"Time for metformin"
→ 85% adherence rate
HEDIS: Med Adherence
Mood Check-ins
"How's your mood today?"
→ 92% PHQ-9 completion
HEDIS: Depression Screen
Symptom Tracking
"Any chest pain today?"
→ 25% readmit reduction
ACO: Utilization
Education Nudges
"Check your feet daily"
→ 20% complication drop
Star: Prevention

How Digital Twin Transforms VBC Performance (100 Patients)

Traditional Care Gaps:
  • Annual visits miss deterioration
  • No engagement between appointments
  • Reactive to acute events
  • Poor medication adherence (50%)
  • Low patient activation (PAM 2)
  • Quality measures at year-end scramble
Digital Twin Solutions:
  • Daily micro-interactions prevent crises
  • 78% daily engagement rate
  • Predictive escalation before admission
  • 85% medication adherence achieved
  • PAM Level 4 in 6 months
  • Real-time quality measure capture

Digital Twin Quality Impact (100 Patients)

Daily Wins
2,340 celebrations
monthly motivation
→
Behavior Change
78% sustained
engagement
→
Clinical Impact
0.8% A1c drop
25% readmit fall
→
VBC Success
$480K savings
4.2 Stars

VBC Performance Metrics (100 Patients with Digital Twin)

92%
PHQ-9 via Avatar
85%
Med Adherence
78%
Daily Engagement
4.2 ⭐
Star Rating
PAM 4
Activation Level
$4,800
Savings per Patient

Why Digital Twin Wins in Value-Based Care

  • Continuous Quality Capture: Every goal check-in and daily win maps to HEDIS measures automatically
  • Behavioral Economics: Gamified daily wins create sustained engagement (78% vs 15% portals)
  • Predictive Intervention: AI detects deterioration from mood/symptom patterns days before crisis
  • Perfect Attribution: Every quality action timestamped and documented for VBC reporting
  • Patient Activation: Daily micro-coaching moves patients from PAM 2 to PAM 4 in 6 months
  • Cost Reduction: $4,800 per patient savings through prevention vs reaction
  • Revenue Bridge: Generate $7,500 monthly from digital twin while building VBC capabilities
8

ACO Metrics: 100-Patient Performance

Achieving Shared Savings at Small Scale

ACO Impact: 100 well-managed CCM patients can generate $180K in shared savings while improving all quality domains, proving the model for larger ACO participation.

100-Patient ACO Quality Domains

Patient Experience
92% satisfaction
100 patients surveyed
+18 CAHPS points
Care Coordination
15 readmissions
(was 20)
25% improvement
Preventive Health
85 patients current
15 gaps remaining
85% compliance
At-Risk (60 pts)
48 controlled
12 improving
80% at target
Clinical Care
92 screened
8 pending
92% completion
Utilization
28 ED visits
(was 35)
20% reduction

Shared Savings Calculation (100 Patients)

Benchmark
$1.2M total
100 patients
$12K each
→
Actual Spend
$960K total
100 patients
$9.6K each
→
Total Savings
$240K
20% reduction
$2.4K per pt
→
Practice Share
$120K
50% distribution
$1.2K per pt

100-Patient ACO Metrics

92%
Quality Score
$240K
Total Savings
$120K
Practice Share
$480K
Combined Revenue

100-Patient ACO Success Strategy

  • Focus on High-Cost: 15 patients drive 50% of spending
  • Prevention Pays: 5 avoided admissions = $60K savings
  • Quality First: 92% scores qualify for maximum distribution
  • Total Revenue: $360K CCM + $120K shared savings = $480K
  • Proof Point: 100-patient success attracts larger ACO contracts
  • Scale Ready: Model proven for 300-500 patient expansion
9

Financial Summary: 100-Patient Model

Complete Revenue & ROI Analysis

Financial Performance: 100 CCM patients generate $360K annual revenue with $480K when including shared savings, achieving 400% ROI in first year with just 3 FTEs.

Revenue Streams (100 Patients)

$30K
Monthly CCM/PCM
$360K
Annual Base Revenue
$120K
Shared Savings
$480K
Total Annual Revenue

Cost Analysis (100 Patients)

Staff Costs
2 Nurses: $140K
Provider time: $10K
+
Platform
$50/patient/mo
$60K annual
+
Operations
Admin support
$30K annual
=
Total Costs
$240K annual
$2,400 per patient

Profitability (100 Patients)

Gross Revenue
$480K annual
$40K monthly
Total Costs
$240K annual
$20K monthly
Net Profit
$240K annual
$20K monthly
50% margin

ROI Metrics (100 Patients)

45 days
Payback Period
100%
First Year ROI
400%
3-Year ROI
$2,400
Profit per Patient

100-Patient Financial Success

Revenue Breakdown:
  • CCM Base: $200K (56%)
  • Add-on Codes: $100K (28%)
  • Complex Care: $60K (16%)
  • Shared Savings: $120K (bonus)
Key Success Factors:
  • Low overhead with 3 FTEs
  • High margin at 50%
  • Scalable to 300 patients
  • Proven quality outcomes
10

4-Month POC Implementation: 100 Patients

Building on Existing ACUITYhealth Infrastructure

Current Foundation (ALREADY DEPLOYED): QHIN/CommonWell integration live with CHI engine generating real-time risk scores. RPM devices collecting data. Patient app 50% complete, Provider portal 35% complete. This foundation accelerates our POC timeline significantly.

Month 1: Complete Core Platforms & Team Formation

Weeks 1-2
✓ CHI identifies 100 patients
Complete patient app (50%→100%)
Digital twin conversations live
Week 3
Complete provider portal (35%→100%)
Add attestation workflow
Charge capture dashboard
Week 4
Hire 2 nurses (RN + LPN)
3-day training on CHI/platform
Patient consent obtained

Month 2: Launch Operations & Ambient Capture

Week 5-6
Deploy ambient capture
Phone/bedside/telehealth
25 patients active
→
Week 7
Scale to 50 patients
Digital twins engaging
500 min captured
→
Week 8
Full 100 patients
Daily huddles smooth
1,500 min captured

Month 3: Revenue Generation & Optimization

Weeks 9-10
First billing cycle
2,000+ minutes documented
$20K claims submitted
Week 11
CHI refines risk stratification
Digital twin personalization
78% engagement achieved
Week 12
First payment received
98% clean claim rate
Process optimization

Month 4: Scale & Quality Demonstration

Week 13-14
3,000 min/month
$30K monthly run rate
Quality metrics improving
→
Week 15
VBC metrics proven
15% readmission drop
85% med adherence
→
Week 16
POC complete
$90K total revenue
Ready to scale 300+
Leveraging Existing Infrastructure:
  • ✓ CHI Engine: Already identifying high-risk patients from QHIN data - no cold start
  • ✓ QHIN/CommonWell: Historical data flowing - immediate risk stratification possible
  • ✓ RPM Platform: Devices deployed - generating billable minutes from day 1
  • ✓ Clinical Decision Support: AI recommendations ready - nurses have immediate guidance
  • → Patient App (50%): Complete digital twin conversations and engagement features
  • → Provider Portal (35%): Add attestation workflow and charge capture dashboards
  • + NEW: Ambient capture layer for phone/bedside/telehealth interactions

4-Month Implementation Metrics

Month 1
Platform Complete
Month 2
100 Patients Live
Month 3
Revenue Flowing
Month 4
$30K/mo Proven
$90K
Total POC Revenue
300+
Ready to Scale

4-Month POC Success Strategy

  • Month 1 Focus: Complete platforms (50% → 100%) while CHI identifies optimal patient cohort
  • Month 2 Achievement: 100 patients engaged with both digital twin and nurse interactions
  • Month 3 Validation: First revenue received, 98% clean claims, processes optimized
  • Month 4 Proof: $30K monthly run rate achieved, quality metrics improved, VBC ready
  • Accelerators: CHI already running, QHIN data flowing, RPM devices deployed
  • Risk Mitigation: Existing infrastructure reduces technical risk - focus only on operations
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
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