Why the Prepared Patient program exists
Most clinicians want to teach patients well and run out of minutes. Patients leave with a leaflet and a follow-up date, and we ask them to manage a serious condition with thin preparation. The result is predictable: avoidable ED visits, readmissions, no-shows, missed adherence, and quietly worsening outcomes.
The Prepared Patient program is the structured curriculum + tools + measurement layer your practice doesn't have time to build. It teaches the patient in plain language, trains a care partner in parallel, and gives you (the provider) the registration workflow, the engagement scripts, and the data — so the team speaks one vocabulary and the work that already pays under existing CMS codes finally gets done.
The three-role architecture
Every condition in the library has parallel layers, all tuned to the same red flags and the same vocabulary:
- Prepared Patient — plain-language course, Force Field Fact Sheet, action plan, certification exam, Advocate Bingo, credential.
- Prepared Care Partner — same depth, tuned to the caregiver job: red rules, red flags, contact ladder, daily tracker, ER go-bag, step-in / step-back, certification exam with Knowledge · Actions · Confidence tracking.
- Prepared Provider (this course) — orientation, enrollment script, incentive map, PHIT dashboard for panel outcomes.
The 30-second in-visit enrollment script
You don't need a new visit type. You need one new sentence at a natural inflection point — new diagnosis, med change, hospital discharge, AWV plan, or pre-procedure conversation.
For full printable scripts (clinic, ED, discharge, AWV), see the companion page:
Engagement workflow — in-clinic, between visits, ED, discharge
In-clinic
- MA opens the patient's chosen Prepared Patient pathway page on the room monitor before you walk in. The visit starts with "let's look at where you are on this."
- Ask the patient to read back the two red rules and the four red flags. This is your fastest competency check.
- If a care partner is in the room — or on the phone — engage them too. Same vocabulary.
Between visits
- The patient's pretest score, post-test score, and K-A-C deltas are exported to PHIT — viewable at the panel level.
- Pair Prepared Patient enrollment with CCM enrollment for eligible patients (2+ chronic conditions). The non-face-to-face minutes are scoped and billable.
- For RPM-eligible cohorts (HTN, CHF, T2D), the program's tracker workflow plugs into the device + minutes thresholds.
ED / Discharge
- Hand the Force Field Fact Sheet at discharge. It's a one-pager with the action plan and the contact ladder — the closest thing to a portable, plain-language hand-off.
- For TCM-eligible discharges (post-hospital), the program's first-call check-in is a natural fit for the 7-day and 14-day touch.
The incentive map — what already pays for this
The program is designed to fit into existing CMS code families and value-based contracts. None of the time below is uncompensated when documented correctly.
| Code family | What it pays for | How Prepared Patient fits |
|---|---|---|
| CCM (99490, 99439, 99487, 99489) | Non-face-to-face care coordination for patients with 2+ chronic conditions, monthly | Care-coordination minutes spent on the program (enrollment, follow-up, action-plan review) count toward the threshold. |
| PCM (99424–99427) | Principal Care Management for a single complex chronic condition | Single-condition deep work (e.g., SCD, CHF, T1D) maps directly to the PCM workflow. |
| RPM (99453, 99454, 99457, 99458) | Device setup, monthly device-data transmission, and monthly clinical minutes | The program's home-tracking pattern (BP cuff, scale, glucometer, pulse ox) supplies the device data; the clinical minutes are spent reviewing it. |
| BHI / CoCM (99492–99494, G2214) | Behavioral health integration in primary care | The mental-health-aware courses (Depression, Anxiety, PTSD, SUD) supply the patient-side curriculum a CoCM team needs. |
| TCM (99495, 99496) | Transitional Care Management — 7- and 14-day post-hospital touches | The Force Field Fact Sheet + first call-back form a clean TCM workflow. |
| AWV (G0438, G0439) | Annual Wellness Visit + personalized prevention plan | List Prepared Patient enrollment in the personalized prevention plan; review uptake at the next AWV. |
| SDOH Z-codes | Documenting social determinants | The onboarding ZIP capture supports SDOH-aware referrals. |
| ACO / VBC | Shared savings, quality-bonus, and capitation contracts | The program drives the metrics most VBC contracts pay on — utilization (ED/readmits), clinical quality, patient experience. |
The full code map with billing notes is here:
ROI & PHIT — the panel-level story
The Force for Health PHIT pipeline collects an anonymous structured payload from every onboarding event and every Care Partner / Patient exam attempt. That gives you, at the panel level:
- Knowledge · Actions · Confidence deltas per condition — knowledge, attitude, and confidence improvement from pretest to post-test.
- Knowledge-score deltas per condition — does the course actually teach.
- Enrollment funnel — how many were offered, how many accepted, how many completed the pretest, how many completed the post-test.
- Outcomes hooks — ED-visit and readmission events can be joined back to enrolled members at the practice level when claims access is in place.
- Even modest reductions in 30-day readmission rates (1–2 percentage points) for CHF / COPD / SCD discharges produce meaningful savings under value-based contracts.
- CCM and RPM revenue at the right enrollment rate covers the staff time before any downstream savings are counted.
- The PHIT export is publication-quality data for your QI committee, IRB, or research partner.
10-question post-test
A short check that the orientation landed. Pass mark 80% (8 of 10). Wrong answers reveal a teaching prompt. Retakes are unlimited.