The Disrupted Podcast

In this episode of The Disrupted Podcast, Jamie and Scott have a raw, specific, and deeply personal conversation about Care Managers: who they are, what they're actually supposed to do, and why getting this role wrong is costing patients their health and organizations millions of dollars. Scott opens with a story that hits hard: his 91-year-old father's recent hospitalization, the mistakes that nearly happened, and what it cost him — financially and emotionally — to navigate a system that wasn't built for the patient. What you'll hear in this episode: Why care managers are controllers, not schedulers — and what happens when organizations get that wrong The medication reconciliation crisis: how discharge errors are sending patients straight back to the ER How Your Health's new geographic mapping tool is transforming how care teams schedule 30 days of visits in advance The shared bonus model designed to stop care team members from fighting over visits — and start winning together What care managers should never be doing — and the analytical skill set that separates great ones from average ones If you're building care teams, leading a healthcare organization, or just trying to keep a loved one safe in a broken system, this episode will change how you think about the people standing between your patients and the hospital. www.YourHealth.Org

What if the most powerful person on your care team isn't a nurse, a doctor, or a specialist — but someone showing up at 8:00 AM to check blood pressure, eat lunch with residents, and play vital signs bingo? In this episode, we go deep on the Community Health Worker role: what it is, what it isn't, and why most organizations are dramatically underusing it. Scott pulls no punches on the disconnect between what CHWs are doing and what they should be doing — and why the difference is costing patients their health and workers their bonuses. What you'll hear in this episode: Why the #1 complaint about CHW visits ("you're seeing our patients too much") is actually a communication failure, not a frequency problem — and how to fix it The specific visit types every community health worker should be scheduling: vital signs, medication reconciliation, lab draws, wound care, advanced care plans, and more How Mary White, a CHW in Gainesville, Georgia, goes in with 5 patients on her list and leaves having seen 15 — and what her approach reveals about what this role is really for Why buildings that aren't growing have either the wrong person or not enough people — and how to think through both The full compensation breakdown: base salary, guaranteed bonus, and how the right CHW can earn close to $80,000 a year If you hire, manage, or are a community health worker, this episode will reshape how you think about the role. Hit play. www.YourHealth.Org

What does it actually take to say yes in healthcare when the system is wired to say no? In this episode of The Disrupted Podcast, Scott takes you straight into the field — from a brand-new administrator in Marietta, Georgia who's already revolutionizing her building eight days in, to a 190-patient facility in Charleston where the real conversation isn't about hospice referrals, it's about whether you have the staff to back it up. Scott gets honest about the moments where healthcare organizations talk a big game but fold when it matters — refusing acute visits to non-panel patients, locking providers into rigid workflows, and hiring bodies instead of talent. He challenges all of it. And he does it with the kind of clarity that only comes from someone who's actually in the buildings, at the dinner tables, and on the phone doing the hard work every day. From a nurse who deserves a Tesla to a wristband that could change emergency response forever, this episode is packed with real stories, bold ideas, and a simple but radical belief: that getting to the yes isn't just good business — it's the whole point of healthcare. If you're a provider, administrator, nurse, or healthcare leader who's tired of the way things have always been done, this one's for you. www.YourHealth.Org

Healthcare didn’t get expensive because patients got worse — it got expensive because the system got fragmented. In this episode of The Disruptive Podcast, Scott Middleton breaks down why hospice can’t live “over there,” separate from primary care, nursing, therapy, and care management.Scott explains the Your Health Hospice rollout, the staffing reality that determines whether integration is real, and the math behind a new model: caseload reductions for nurses when hospice patients are added, plus incentives that acknowledge the complexity of end-of-life care.This conversation is about building a care system where the patient doesn’t have to juggle providers, phone numbers, and handoffs — because they shouldn’t have to. One team. One plan. One umbrella. www.YourHealth.Org

In this episode, Jamie and Scott discuss a simple leadership posture that changes outcomes: default to “yes” when it protects patients—then solve the obstacles. Scott shares real examples from winter-storm outreach, hospice and palliative care misconceptions, and operational “rules” that block care (often driven by language, software, or habit—not true limitations). They dig into how patient-centered thinking, clearer communication (ditch the acronyms), and smarter systems—like a new mapping tool—can drive more visits, better coordination, and better results. www.YourHealth.Org

In this episode of The Disrupted Podcast, Scott Middleton returns from the JP Morgan healthcare conference with a blunt takeaway: the future of care is not a magic pill, another telehealth platform, or a clever financial structure — it’s showing up. Scott breaks down why healthcare has become unnecessarily complicated, how fee-for-service incentives distort decision-making, and why “easy-entry” models won’t hold up long-term.He makes the case that Your Health’s home-based care model is hard to replicate because it requires operational excellence—routing, scheduling, team coordination, and intentional touchpoints. Scott also challenges internal culture issues: finger-pointing, poor communication, inefficient scheduling, and employees misunderstanding the mission. The solution is both simple and demanding: build systems that make weekly in-person encounters possible for high-risk patients and hold the line on execution. www.YourHealth.Org

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 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. www.YourHealth.Org

00:00 – Welcome & Atlanta Traffic Humor03:12 – Why Atlanta’s Senior Healthcare System Is “Almost Nonexistent”09:15 – Hospitals begging for help & broken discharge processes14:00 – Upcoming cuts to home health and rehab penalties18:45 – Why therapy services need massive, immediate expansion23:18 – The dementia support group story and the power of proactive care30:52 – How storytelling improves patient and family understanding36:44 – Hospice misconceptions & how Your Health does it differently43:17 – Explosive growth in Atlanta and why competition is failing49:10 – Creativity as a core ingredient of healthcare54:40 – Why every associate needs a mentor immediately59:25 – A call to action: show up, ride along, and support Atlanta providers www.YourHealth.Org

Show Notes / SummaryWhy launch hospice now: continuity, fewer hospitalizations, value-based alignmentClarifying myths: CNA hours on hospice, attending provider still leads careRAF & staffing logic: ~$6k/mo hospice per diem ↔ RAF ~5; translating RAF → weekly CNA/CHW hoursNurse incentives: $150 per admission; double telehealth-assist credit on hospice patientsSoftware + workflow: Athena ↔ WellSky (care plans, documentation, pull-through)Facility model: converting buildings; estimating FTEs from hospice census + RAFChaplain/social work: leverage in-region LSWs; connect to patient’s faith communityRespite options: Medicare respite/GIP + GUIDE program for dementia (up to $2,500yr)Therapy as palliative strength: weekly PTA/COTA; telehealth supportAfter-hours model: optional call, $300 RN death/critical visit; $150 for non-nurse critical checksGuardrails: 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

Show NotesWhy transitional care is at the heart of Your Health’s modelHow incentives for early post-hospital visits worked (and why they didn’t)Why in-person care matters more than telehealth aloneThe growing role of respiratory therapists, physical and occupational therapists, and community health workersThe challenge of patient perception: “too many visits” vs. “too many calls”Why insurance companies trying to become providers is dangerous for patientsScott’s philosophy: nothing should be written in stone — adapt and evolveThe simple but powerful call to action for providers: “Go see your damn patients.” www.YourHealth.Org

Key Topics:How sudden insurance and policy changes disrupt patients and providersThe importance of prevention and primary care in lowering long-term costsWhat fully staffed care teams look like and why they matterBalancing productivity and patient-centered careWhy disruption is necessary for a healthier futureTakeaway: Healthcare continues to be shaped more by profit and red tape than by prevention and patient outcomes. But with innovative care models and a relentless focus on what patients truly need, leaders can shift the system toward better health and lower costs. www.YourHealth.Org