KEY TAKEAWAYSThe 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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