Solutions · ACOs & risk-bearing organizations
Responsible for every patient. In the room with almost none of them.
Shared savings, Medicare Advantage, an attributed panel — every risk arrangement holds the same asymmetry. The result is decided between visits, by patients you rarely see, inside practices you do not run. LifeWatch is built for exactly that position.
A measure is a number. The work behind it is patients.
Every number you are judged on resolves to a set of people, and moves only when something happens to them. LifeWatch runs that whole chain in one place, so the number and the work behind it never disagree.
- 01
The contract, or the measure
A shared-savings target, a Star measure, a HEDIS gap rate — the number you are judged on.
- 02
The patients behind it
Resolved to one record each from roster, claims and whatever the practices can send, with the reason each one qualifies.
- 03
Continuous work
Contact at the program's cadence: gaps worked, adherence followed, transitions covered, needs routed, change escalated.
- 04
An attributable record
Every closure and every escalation carries the contact that produced it, so when the number moves you can say what moved it.
What happened lands back on the record and in the next question you ask of the panel — so next month's number starts from this month's work.
Gaps worked, not listed.
A quality gap here is outreach with a recorded ending, in one of four states. A decline keeps its reason, and unreachable has a definition — so the list your quality team inherits is honest.
Attributed panel · this month
Attributed patients
24,816
One record each, resolved from roster, claims and connected sources
Enrolled in a program
7,410
By the criteria each care program sets
Contacted this month
6,988
Voice and text, at the program’s cadence
Escalated to a care team
214
Each with the transcript and the triggering sentence
Care-gap outreach · an outcome for every gap worked
Declined records the patient’s reason in their own words — this month, most often transportation. Unreachable means the agreed attempts were completed, not one voicemail.
Four things move your number. Here is the mechanism against each.
No projected savings and no modeled ROI — you have seen those slides. Here is the mechanism, plainly. Further down is what a pilot on your own panel would measure.
- 01
Avoidable utilization
The riskiest stretches — after a discharge, while a condition drifts between visits — get scheduled contact. A finding that meets the program’s escalation criteria reaches the patient’s own care team while there is still time to act, not in next quarter’s claims.
- 02
Open care gaps
A gap stops being a row on a list. Outreach explains the visit, answers the objection, and moves the booking. When the patient declines, the real reason is recorded — so the list reflects work done, not attempts logged.
- 03
Under-documented complexity
A condition that lives only in a free-text note or a scanned document counts for nothing. The layer that prepares every contact reads those sources, makes what they hold structured and findable, and keeps the sentence each value came from.
- 04
Unreached patients
Contact runs at the cadence each program sets, not the cadence staffing allows. Routine needs close on the contact; only findings that need a clinician reach one. Coverage grows across the panel without headcount growing with it.
For finance and compliance: the position, the billing alignment, the three numbers we will not give you, and the pilot
You do not run their systems. The program does not assume you do.
It starts from data you already hold
An attribution roster, claims, an export. LifeWatch resolves them into one record per attributed patient. Nothing sits on a participant practice’s IT queue.
It connects where a practice wants it
Standards-based interoperability into a practice’s record, when that practice chooses it. Nothing they run is replaced, and no practice has to adopt anything for its patients to be covered.
Escalations land with the patient’s own clinicians
A finding goes to the care team that knows the patient — with the transcript, the triggering sentence, and the change against that patient’s own baseline. The documentation follows it.
Documented for the codes your practices already bill.
Advanced Primary Care Management pays a flat amount per patient per calendar month, with no time thresholds to tally. Chronic Care Management remains the time-based alternative. Several of APCM's CMS-defined service elements describe work LifeWatch performs continuously — the element names below are CMS's, not ours.
- G0556APCM Level 1Zero or one chronic condition
- G0557APCM Level 2Two or more chronic conditions
- G0558APCM Level 3Two or more chronic conditions, Qualified Medicare Beneficiary
- 99490CCMTime-based; two or more chronic conditions
- Worth reading twice: APCM Level 1 covers patients with zero or one chronic condition — patients time-based CCM could never reach. Care management stops being a service for the sickest slice and becomes one the whole panel can be enrolled in.
- Enhanced communication
- Contact between visits on the cadence the condition calls for, in the channel the patient actually answers.
- Management of care transitions
- Structured follow-up through the window after a discharge, when contact is thinnest and risk is highest.
- Population-level management
- Risk stratification across the panel using diagnoses, claims and other connected data, so outreach targets who needs it.
- Care coordination
- Routine needs routed and closed — scheduling, refills, education, open care gaps — rather than queued for a nurse.
- Comprehensive care management
- Condition-specific programs with defined checks, running continuously rather than at the visit.
LifeWatch documents the contact. Your practice performs and bills the service — we never bill on your behalf, and nothing here is billing advice.
Three numbers you will never get from us.
Organizations that hold risk are the most heavily pitched audience in healthcare, and most of the pitches lean on numbers nobody can audit. Ours cannot, on principle:
A percentage we cannot stand behind
We publish no outcome figures, because we have none we could defend to your actuaries. What a pilot will show is agreed with you before it starts, and reported against — nothing else.
A gap marked closed that was only attempted
Outreach records its outcome: booked, declined with the reason, or unreachable after the agreed attempts. Your quality reporting inherits an honest list.
A measure computed over data we do not have
Measures resolve against the data actually connected. Where data is missing, the measure says so — instead of returning a number you cannot defend at reconciliation.
How escalation detection is evaluated — the rubric, what is scored, and why false alarms count against it — is documented at How we test.
Measured on your terms. Started without anyone's IT queue.
How it starts
A pilot begins from the data you already hold — a roster, claims, an export — resolved into one record per attributed patient. Deeper connection into practice records follows where the participants want it.
The clinical content arrives finished — our clinicians author and certify each program, and your team reviews it in full. You decide who is enrolled, on what cadence, and where escalations go. The full model is at Clinical design.
What it measures
- Reach
- The share of the enrolled panel actually contacted each month, by program.
- Gap outreach outcomes
- Booked, declined with a recorded reason, or unreachable after the agreed attempts — per gap worked, not per attempt.
- Documentation
- Patient months with care-management documentation produced, in the form your practices bill from.
- Escalations
- Findings raised and delivered to the patient’s own care team, and how many were confirmed on review.
Bring us the panel you are on the hook for.
One attributed population and the contract behind it. We will walk the mechanism against your own numbers, and agree the measures before a pilot starts — so the first report is judged on terms you set.
Talk to our team