In this first Disrupted Podcast episode of 2026, Jamie and Scott unpack the reality of a new “High Needs ACO” and what it demands from frontline care teams. Scott explains why spending more in primary care reduces total cost, how care management codes are expanding, and why the real win is keeping patients out of the hospital through proactive, consistent engagement.

The centerpiece is a clear operational playbook for facilitated visits: facilitators gather the full story in the home or facility, loop in the provider through audio/video when possible, document in the system, and never delete encounters—because billing isn’t just revenue, it’s the data trail that proves prevention works. The conversation closes with the bigger picture: this isn’t a workflow tweak—it’s a way to reduce hospital dependency, protect families, and help stabilize the healthcare economy.

www.YourHealth.Org

In this episode of The Disrupted Podcast, Jamie and Scott break down what’s really happening inside healthcare facilities—and why the problem isn’t complexity, but misalignment. Through a real-world walkthrough of one provider’s experience, Scott unpacks the Facility Model, explaining how proper staffing, proactive care, and smarter use of hospice, telehealth, and community health workers can radically improve outcomes for patients, providers, and facilities alike. This conversation pulls back the curtain on how healthcare systems unintentionally block good care—and how simple, human-centered adjustments can change everything.

www.YourHealth.Org

In this episode of The Disrupted Podcast, Jamie sits down with Chief Disruption Officer Scott Middleton to unpack what’s really holding healthcare organizations back from sustainable growth — and it’s not demand. From inefficient scheduling and fragmented care teams to missed opportunities in behavioral health, hospice, and regional expansion, Scott lays out a candid blueprint for how ownership thinking, smarter systems, and physical presence in communities can radically improve outcomes.

Through real-world examples, Scott explains how a new map-based scheduling model, regional restructuring into divisions, and empowered frontline teams can increase productivity by 20% overnight — while simultaneously reducing ER visits, hospitalizations, and burnout. The conversation ultimately reframes growth not as a staffing problem, but as a leadership, coordination, and accountability challenge.

www.YourHealth.Org

KEY TAKEAWAYS

• The 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.

www.YourHealth.Org

00:00 – Welcome & Atlanta Traffic Humor
03:12 – Why Atlanta’s Senior Healthcare System Is “Almost Nonexistent”
09:15 – Hospitals begging for help & broken discharge processes
14:00 – Upcoming cuts to home health and rehab penalties
18:45 – Why therapy services need massive, immediate expansion
23:18 – The dementia support group story and the power of proactive care
30:52 – How storytelling improves patient and family understanding
36:44 – Hospice misconceptions & how Your Health does it differently
43:17 – Explosive growth in Atlanta and why competition is failing
49:10 – Creativity as a core ingredient of healthcare
54:40 – Why every associate needs a mentor immediately
59:25 – A call to action: show up, ride along, and support Atlanta providers

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Show Notes / Summary

• Why launch hospice now: continuity, fewer hospitalizations, value-based alignment
• Clarifying myths: CNA hours on hospice, attending provider still leads care
• RAF & staffing logic: ~$6k/mo hospice per diem ↔ RAF ~5; translating RAF → weekly CNA/CHW hours
• Nurse incentives: $150 per admission; double telehealth-assist credit on hospice patients
• Software + workflow: Athena ↔ WellSky (care plans, documentation, pull-through)
• Facility model: converting buildings; estimating FTEs from hospice census + RAF
• Chaplain/social work: leverage in-region LSWs; connect to patient’s faith community
• Respite options: Medicare respite/GIP + GUIDE program for dementia (up to $2,500yr)
• Therapy as palliative strength: weekly PTA/COTA; telehealth support
• After-hours model: optional call, $300 RN death/critical visit; $150 for non-nurse critical checks
• Guardrails: clinical judgment first; financials inform—not dictate—care

www.YourHealth.Org

Key Takeaways (for on-air recap & social)

• Presence prevents: Being in the building daily beats any remote administrative stack.
• Rituals > heroics: Small, repeatable actions (exercise + vitals + lunch checks) compound.
• Caregivers stabilize: A modest weekly schedule creates 40 hours of reliable on-site support.
• Therapy cadence matters: Spread the care; keep people moving longer to reduce falls.
• Document to decide: Specific behavioral notes → faster NP decisions → fewer crises.
• Mission creates growth: Aligning to “no hospitalizations” reduces noise and increases referrals.

www.YourHealth.Org

Why transitional care is at the heart of Your Health’s model

How incentives for early post-hospital visits worked (and why they didn’t)

Why in-person care matters more than telehealth alone

The growing role of respiratory therapists, physical and occupational therapists, and community health workers

The challenge of patient perception: “too many visits” vs. “too many calls”

Why insurance companies trying to become providers is dangerous for patients

Scott’s philosophy: nothing should be written in stone — adapt and evolve

The simple but powerful call to action for providers: “Go see your damn patients.”

www.YourHealth.Org