ACP for Healthcare

• 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 annual platform subscriptions with maintenance and support, per member per month pricing for ACP delivered in capitated or alternate payment models, and 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.).

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.

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.

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.

• 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

• 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

• 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

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.