ACP for Healthcare

We make it easy to help people discuss, document, and share what is important about their health care so their decisions are honored.

Effective ACP

A successful ACP ecosystem in diverse healthcare contexts

Our ACP software and implementation services are designed to overcome provider delivery barriers and address the problems with paper-based ACP forms while making adding effective ACP services easy.

Our ACP software-as-a-service helps many types of healthcare organizations deliver high quality, consistent advance care planning services. Family and community health clinics provide an important service to Medicare patients (at no cost to the patient) and earn additional revenue by easily adding ACP sessions to Annual Wellness Visits (AWVs).
Skilled nursing facilities and long-term care centers benefit from ACP facilitator training, a structured approach to comprehensive ACP, and online update and storage of completed digital advance care plans that follow people through care transitions. CMS innovation model participants where ACP is a required care transformation requirement or quality measure (e.g., Primary Care First, Radiation Oncology Model, and BPCI Advanced) improve their performance. Organizations in shared risk models lower total cost of care while providing better quality end-of-life care that aligns with people’s values.

Discover how you can deliver an effective ACP program across care settings

Flexible ACP

A variety of delivery channels and pricing models

  • ACP can be completed independently or with the assistance of a facilitator, either in person or virtually.
  • Telehealth ACP can be easily and seamlessly delivered by existing staff in chronic care management, disease management, complex case management, advanced illness coordinated care, and other programs.
  • In-clinic ACP can support health providers – from care managers to network physicians – in facilitating, documenting, and earning reimbursement for ACP.
  • Channel agnostic: ACP education and engagement can be delivered via email, website, SMS, member portal, and other channels.
  • Pricing options include a per session fee for ACP sessions delivered through the ACP Facilitator Portal, per member per month pricing for ACP delivered in capitated or alternate payment models, blocks of Honor My Decisions subscriptions (with volume discounts) to support outreach programs (e.g., ACP talks at senior centers, faith-based organizations, community health fairs, universities, etc.), and per seat subscriptions of the ACP Facilitator Portal with quarterly maintenance and support for departments or programs within healthcare systems where the per ACP session pricing model is not applicable.

 Quality ACP

Supports quality measures and improvement activities

Our structured approach to comprehensive advance care planning, staff training, and implementation services help improve performance on the high priority Advance Care Plan (Quality ID 47, NQF 0326) quality measure that is part of the Medicare Quality Payment Program’s Merit-Based Incentive Payment System (MIPS) and several CMS Innovation Models as well as the MIPS population management Advance Care Planning improvement activity.

Holder
Advance Care Plan (Quality ID 47, NQF 0326)

This is a high priority process measure in the Communication and Care Coordination National Quality Strategy domain.

Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.

This measure is part of the following MIPS specialty measure sets:

  • Cardiology
  • Certified Nurse Midwife
  • Clinical Social Work
  • Family Medicine
  • Gastroenterology
  • General Surgery
  • Geriatrics
  • Hospitalists
  • Internal Medicine
  • Nephrology
  • Neurology
  • Obstetrics/Gynecology
  • Oncology
  • Orthopedic Surgery
  • Otolaryngology
  • Physical Medicine
  • Preventive Medicine
  • Pulmonology
  • Rheumatology
  • Skilled Nursing Facility
  • Thoracic Surgery
  • Urology
  • Vascular Surgery
Advance Care Planning Improvement Activity

This is a medium weight improvement activity in the population management subcategory.

Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.

REIMBURSABLE ACP

Earn revenue for ACP sessions while improving patient care

Advance care planning helps people have a voice in their health care and can provide the additional benefit of fee-for-service revenue if you bill for ACP sessions under CPT codes 99497 and 99498. Our ACP program fits into your workflow without placing additional burdens on your providers. You can even leverage existing visits by adding ACP sessions to Annual Wellness Visits or Chronic Care Management and increase the value of these visits for your patients and you. Your providers are already having conversations with patients and families to honor their wishes to the best of their abilities, but you need a formal system in place to reliably capture and access people’s advance care plans, ensure conversations take place, and provide the documentation necessary to bill payors.

  • Training and customizable implementation materials for front desk, scheduling, clinical, and billing staff ensure successful ACP program implementation.
  • Supports a team-based approach to boost reimbursable ACP session delivery for both medically-necessary ACP and ACP in conjunction with Medicare Annual Wellness Visits.
  • Session timers, ACP educational content to use during sessions (videos, worksheets, and handouts), and system-generated Medicare-compliant documentation in our ACP Facilitator Portal make the delivery of high-quality, consistent ACP sessions easy for any staff member regardless of their experience.
  • ACP tools and workflows support facilitated in-person as well as video or audio-only telehealth ACP sessions.
  • Aligns with existing ACP programs by providing the technology to enhance established ACP methodologies, supporting healthcare system specific ACP forms and processes, and integrating with EHRs.

accessible ACP

Easily find the information to honor values and preferences

All parts of a person’s advance care plan are available 24/7 via a personalized URL in our ACP Authority repository. This URL is stored within the person’s medical record in the EHR ensuring that the care team always has access to the person’s most recent advance care plan. It is also provided on a wallet card with a scannable QR code that the person can print and carry with them. This ensures that the person’s most recent decisions and preferences can always be found, addressing provider concerns about not reliably recording patient wishes and storing outdated advance directives in the EHR. It reassures the care team that they have an accurate record of the person’s preferences and values to guide care (unlike a paper-based form). It also fixes the accessibility problem of paper-based advance directives as it is not locked away in a safety deposit box or lost in a drawer.

  • Secure cloud-based repository stores each advance care plan at a unique URL and is available 24/7.
  • Includes all elements of a person’s comprehensive ACP: emergency contacts, healthcare decision-maker, treatment preferences, legal documentation, end-of-life values, and video living will.
  • Access via a QR code on the wallet card, share emails, and a link stored within the EHR.

ACP for ACOs

Reduce unwanted medical care and increase shared savings

Our ACP software-as-a-service will improve care coordination for your members across care settings.

Effective ACP support for your clinicians and members results in better clinical outcomes, higher satisfaction, and members receiving care in the setting that aligns with their personal goals and values.

Our education for clinicians and other staff, ACP session tools, member engagement, and comprehensive, structured ACP ecosystem provides an end-to-end solution to ensure an effective ACP program that results in complete digital plans that can be found, understood, and honored whenever and wherever they are needed.

  • Connect clinicians across care settings
  • Reduce unnecessary healthcare utilization
  • Increase program shared savings
  • Deliver high-quality care at lower cost
  • Generate revenue by billing ACP CPT codes 99497/99498
  • Provide goal concordant care
  • Support telehealth ACP services
  • Achieve value-based quality measures

ACP for Health Systems

Deliver more goal concordant care and less unwanted care

Our ACP software-as-a-service will improve the end-of-life experience for your patients as well as their families and your clinicians as you deliver care that aligns with people’s individual goals and preferences.

Our education for clinicians and other staff, ACP session tools, patient engagement, and comprehensive, structured ACP ecosystem provides an end-to-end solution to ensure an effective ACP program that results in complete digital plans that can be found, understood, and honored whenever and wherever they are needed.

  • Support shared decision-making
  • Increase patient, family, and caregiver satisfaction
  • Reduce unwanted medical treatments at end-of-life
  • Achieve value-based quality measures
  • Reduce unnecessary hospital admissions
  • Achieve total cost of care savings
  • Improve patient, family, and clinician experience
  • Reduce unnecessary ICU utilization

ACP for Post-Acute Care

Accessible ACP as people move between care settings

Our ACP software-as-a-service will ensure that people’s individual care goals and preferences follow them as they transition between care settings. We make it easy for you to discuss and update their treatment wishes that may evolve with their changing health condition.

Our staff training, patient engagement, and comprehensive, structured ACP ecosystem provides an end-to-end solution to ensure an effective ACP program that results in complete, up-to-date digital plans that can be found, understood, and honored whenever and wherever they are needed.

  • Access and share care plans across care settings
  • Reduce readmissions
  • Provide goal concordant care
  • Reduce unwanted medical treatments at end-of-life
  • Achieve value-based quality measures
  • Refer people to appropriate care settings
  • Improve patient and caregiver experience
  • Capture comprehensive digital ACP

ACP for Value-Based Care

Achieve quality metrics and care requirements

Our ACP software-as-a-service can help organizations participating in CMS Innovation Models where ACP is a required quality measure or care requirement improve their performance and maximize payments.

Our staff training, patient engagement, and comprehensive, structured ACP ecosystem provides an end-to-end solution to ensure an effective ACP program that results in more ACP engagements and the capture of healthcare decision-maker selections and advance directives in the electronic medical record. 

Holder
Bundled Payments for Care Improvement Advanced (BPCI Advanced)

The Advance Care Plan quality measure is required for all Clinical Episodes in the BPCI Advanced Model. We can help your staff have more high-quality ACP conversations with these patients, improving your quality measure performance and ensuring that people’s health care wishes are captured in the medical record and available when needed. Support for telehealth ACP and in-person ACP helps you generate revenue from billing CPT codes 99497/99498 for these ACP interactions.

Primary Care First
The Advance Care Plan quality measure is a required Quality Gateway measure for all risk groups in Primary Care First. We can help your staff have more high-quality ACP conversations (both in-person and via telehealth) with these patients, improving your performance and ensuring that people’s health care wishes are captured in the medical record and available when needed.
Radiation Oncology (RO) Model
The Advance Care Plan quality measure is one of the four required quality measures in the mandatory RO Model. We can help your staff have more high-quality ACP conversations with these patients, improving your quality measure performance, earning back more of your quality withhold, and ensuring that people’s advance care plans are captured in the medical record and available when needed.
Medicare Advantage (MA) Value-Based Insurance Design (VBID) Model

In 2023, the Wellness and Health Care Planning (WHP) intervention is required for all MA plans in the VBID Model. WHP is defined as “timely, coordinated approaches to wellness and health care planning, including advance care planning.” Our end-to-end, structured ACP program can help you effectively meet the ACP requirements of WHP while at the same time ensure that your members receive better quality care aligned with their values and preferences.

Need help?

Hi! We’re technology and education professionals with healthcare backgrounds who have all personally experienced the importance of advance care planning. The Alpha-1 Foundation is a part owner of our company. By using our services, you help their mission to find a cure for alpha-1 antitrypsin deficiency and help people breathe.

Don’t hesitate to reach out if you have a question about our services or need help with your advance care planning. Our support team will quickly connect you with the right person.

support@honormydecisions.com

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