People, process, and technology integration for day-one readiness
§5.1 HR & Hiring Plan§5.2 Transport & Logistics§5.3 Clinical Operations§5.4 Systems & Technology§5.5 Community Partnerships§5.6 Visual Deliverables
Launch Team
6 roles · pre-launch
Visits / Day
8–12 target
Anchor Partners
Faith + NGHS + SNF
EHR Decision
Athelas AIR or Athenahealth
↓Begin
Stage 5 · Operations & Business Processes · Section 5.1
HR Management — Hiring Plan & Team Structure
Who to hire first, in what order, and what each role is accountable for. The sequence is non-negotiable — the NP and compliance function must be in place before the first patient.
Order is non-negotiable · each hire unlocks the next compliance or operational milestone
1
NP / APRN — Primary Clinician
Hired first. NPI, GA licensure, and Nurse Protocol Agreement cannot be filed without a named clinician. Drives the PECOS enrollment clock (60–90 day processing). In-clinic or remote hub model — the fixed clinic is their base. $125K base · $156,250 loaded.
Month 1 · triggers CMS PECOS enrollment clock
2
Medical Director — Supervising MD
Signs Nurse Protocol Agreement (filed with GA Composite Medical Board). Available via phone/Doxy.me during all clinical hours. Retainer structure ($36K–$54K/yr) avoids full-time W-2 overhead at launch. Serves as CLIA lab director.
Month 1–2 · concurrent with NP onboarding
3
Compliance & Operations Lead
FWA training program, HIPAA BAA execution, OSHA clinic setup, written compliance policies, OIG exclusion screening cadence. Doubles as operations manager in Phase 1. Must be in place and compliant before first patient — not simultaneously.
Month 2 · before clinic go-live
4
LPN — Field Clinical Support
GA-licensed. Phlebotomy training documented before first blood draw (GA permits LPN blood draw — not automatic). ADA clinic orientation, OSHA bloodborne pathogen training. Works under NP supervision. $52K base · $65K loaded.
Month 2–3 · before first patient encounter
5
Care Coordinator — Remote
Manages CCM time documentation (Chronic Care IQ), RPM alert monitoring (Tenovi dashboard), member scheduling (Klara), TOC outreach cadence (Bamboo PatientPing), referral tracking. 300–600 members per FTE. Critical for CCM revenue. $55K base · $68,750 loaded.
Month 3 · before first CCM bill is submitted
6
Driver — Transport & Logistics
Member transport to fixed clinic, vehicle logistics, route optimization. Background check + clean driving record + HIPAA training before first member transport. Samsara fleet tracking for mileage log (IRS required) and maintenance alerts. $45K base · $56,250 loaded.
NP: Documentation turnaround (same-day)≥90% of encounters
LPN: Visits completed per day8–12 target
LPN: Member no-show rate<15%
Care Coord: CCM time log completion100% by month-end
Care Coord: RPM alert response (<24 hr)≥95% of alerts
Billing: Clean claim rate (first pass)≥92%
Billing: Days in A/R<35 days
All staff: FWA + HIPAA training100% before go-live
All staff: OIG exclusion screeningMonthly (Compliancy Group)
Compensation — Pre-Launch Clinic Team
GA market rates 2025–2026 · 25% benefits load on all W-2 · driver included per clinic
NP/APRN (W-2, in-clinic)$125K → $156,250 loaded
Medical Director (1099 retainer)$30K–$54K
LPN (W-2, field)$52K → $65,000 loaded
Care Coordinator (W-2, remote)$55K → $68,750 loaded
Driver (W-2, logistics)$45K → $56,250 loaded
RCM/Billing (Commure RCM outsourced)4% of net collections
Per-clinic clinical team (approx.)~$380–420K/yr (Stages 1–2)
Backup staffing: Per-diem LPN pool from a healthcare staffing agency on standby. Cross-train Care Coordinator on basic scheduling and member outreach. No single point of clinical failure.
Stage 5 · Operations & Business Processes · Section 5.2
Transport & Logistics — Member Transport, Routes & Daily Operations
The van is a logistics asset — it brings members to the fixed clinic. Care is delivered at the permanent location. One driver per active clinic, AM pickup → clinic hours → PM return.
§ 5.21 driver / clinic · $56,250 loaded Van = logistics only Samsara fleet tracking
Transport Model — Fixed Clinic with Member Pickup
Van delivers members to clinic · all care at fixed ADA-compliant location · 1 van per active clinic
Core Principle
The van brings members to the clinic. The clinic delivers the care.
All clinical services, examinations, lab testing, and documentation happen at the fixed clinic. The transport van picks up members who cannot self-drive — returns them after the visit. Van contains: driver, basic first aid kit, tablet for scheduling. No clinical equipment. This distinction matters for CMS billing compliance.
AM Route — Member Pickup
7:30–9:00 AM · Route planned prior afternoon
Samsara or OptimoRoute clusters pickups by geography. Driver picks up scheduled members from home or community site. Typical: 4–8 pickups per route. All pickups logged in EHR scheduling system.
Clinic Hours — Driver Standby
9:00 AM – 3:30 PM · Driver at clinic or nearby
Driver assists with clinic logistics (supply delivery, member check-in support). Vehicle parked at clinic — visible to community, reinforces brand presence. Available for urgent needs.
PM Route — Member Return
3:30–5:00 PM · All transported members returned
All members returned to home or community site. Driver logs mileage (IRS required). Vehicle fueled, restocked if needed. Samsara records route completion automatically.
Daily Clinic Operations Flow
Monday–Friday · 7:30 AM huddle → 5:00 PM clean claim close
LPN prepares exam room, Vital Signs Station, i-STAT POC lab supplies. Driver departs on AM pickup route. EHR loaded with day's schedule and AI pre-visit notes.
3
9:00 AM – 3:30 PM — Encounters
8–12 visits/day. Each: AI-assisted intake (10 min) → NP exam via Doxy.me or in-clinic (15–20 min) → checkout, care plan update, next visit scheduled. Commure Ambient scribes in real time.
4
4:00 PM — Documentation Window
NP closes all visit notes (Commure AI drafts, NP validates). LPN restocks, disposes sharps per OSHA. Care coordinator reviews RPM alerts and updates Chronic Care IQ time logs.
Weekly: sanitation, supply check. Monthly: oil, fluids, tire pressure. Quarterly: full service per van schedule. Annual: GA vehicle inspection. All scheduled in Samsara maintenance module.
Breakdown Response
Rental standby contract (Enterprise/Penske) activated within 2 hours. Care coordinator reschedules all affected members. Priority: RPM-enrolled and TOC patients within 30-day window.
Mileage & Fuel
IRS mileage log auto-maintained via Samsara GPS. Fuel card issued to driver — single account. Target: <$0.55/mile all-in. Samsara monthly report feeds MSO ops review.
Stage 5 · Operations & Business Processes · Section 5.3
Day-to-day clinical workflow from member check-in through visit completion, monthly CCM/APCM documentation, RPM monitoring, and escalation decision tree. Every step is billable or compliance-critical.
Every encounter follows the same protocol · Commure AI scribes in real time
①
Member Check-In & AI Intake (10 min)
Klara SMS check-in. LPN captures vitals (Vital Signs Station: BP, weight, SpO2, temperature). i-STAT POC lab if ordered. Commure AI surfaces prior visit note, medication list, active diagnoses, care gaps, RPM alerts. Structured pre-visit note pushed to NP before exam room opens.
②
NP Exam (15–20 min)
NP conducts clinical assessment — in-clinic or via Doxy.me. Commure Ambient scribes in real time. NP diagnoses, prescribes, orders labs, codes visit. LPN present throughout. Documentation complete before member exits.
③
Care Plan Update & CCM/APCM Check
NP updates care plan in Chronic Care IQ. Confirms monthly CCM/APCM clock status. If AWV visit: initiates CCM/APCM consent and enrollment workflow. Care coordinator notified of new enrollments in real time.
④
Checkout & Next-Visit Scheduling
LPN schedules next appointment before member leaves. QMB status verified in EHR — coinsurance billing suppressed automatically. Member receives written visit summary (CMS CCM requirement).
⑤
Same-Day Claim Submission
NP validates Commure AI note → Commure RCM charge capture → billing review → Novitas J-6 submission. QMB flag confirmed. HPSA modifier QB/QU applied to eligible E&M/AWV/TOC. Target: zero next-day unbilled encounters.
CCM / APCM & RPM Monthly Protocol
Non-visit recurring revenue · runs every month between encounters
CCM Monthly Checklist (per member)
□ 20-min contact clock running · activity-specific log entries □ Care plan reviewed and updated this month □ Medication reconciliation documented □ Specialist referral follow-up logged □ Member consent on file and current □ NP co-signature on monthly note before claim
APCM Monthly (G0558/G0557/G0556)
□ Enrolled with signed consent on file □ Active care plan maintained in EHR □ No concurrent CCM for same member same month □ Eligibility confirmed (QMB status for G0558)
RPM Monthly Checklist
□ ≥16 days transmitted data (99454) · or 2–15 days (99445 new 2026) □ Staff clinical review ≥20 min documented (99457) □ Alert events logged with response action + timestamp □ Tenovi server log exported for audit
Escalation Protocol — LPN Field Decision Tree
Every condition has a predefined pathway · LPN never acts unilaterally
Stable, routine: LPN completes intake vitals, NP conducts exam. Standard encounter — no escalation.
Elevated concern (BP >180/110, SpO2 <92%, acute pain): LPN alerts NP immediately. NP decides: manage in-clinic, urgent consult, or direct to ER. LPN does not act without NP direction.
Life-threatening (chest pain, FAST stroke signs, unresponsive): LPN calls 911 + NP simultaneously. NP stays on line directing LPN until EMS arrives. Document exact time, presentation, actions.
Post-escalation: Care coordinator initiates TOC protocol (Bamboo PatientPing). NP coordinates with NGHS receiving hospital. Full escalation chain documented in EHR within 2 hours.
Transition of Care & Quality Metrics
TOC is both a revenue opportunity and an NGHS relationship · HEDIS metrics support CMMI pathway
TOC Protocol (Bamboo ADT)
ADT discharge notificationWithin 24 hr
7-day telephone follow-upCPT 99495
30-day face-to-face visitCPT 99495/99496
30-day readmission target<12%
HEDIS Measures (tracked)
Annual Wellness Visit rate≥80% of panel/yr
HbA1c control (diabetics)<8 for ≥70%
BP control (hypertension)<140/90 for ≥65%
Medication adherence (PDC)≥80%
CMMI Documentation
Track ER visits and hospitalizations per-member pre- and post-enrollment. Document CMS savings at county level via Looker Studio. At 400 enrolled members with ≥$3.36M documented savings, this package supports the CMMI Innovation Award application.
Stage 5 · Operations & Business Processes · Section 5.4
Systems & Technology — Stack, Architecture & Workflow Integration
The finalized technology backbone — EHR, AI documentation, CCM platform, RPM, billing, connectivity, and fleet. All systems selected, priced, and integrated end-to-end from intake to Novitas J-6.
§ 5.4EHR: Athelas AIR / Athenahealth Commure RCM + Ambient AI Novitas J-6 · HIPAA-grade
EHR — Final Two Candidates
Selection required by Month 2 · must be live before first billable encounter
Candidate A — AI-Native
Athelas AIR
AI-native EHR built for value-based primary care. Strong CCM/APCM workflow integration. Native Commure compatibility. Purpose-built for chronic care management model. Confirm offline mode and Novitas J-6 EDI in demo.
Candidate B — Cloud-Native · Large Network
Athenahealth
Cloud-native, strong billing integration, HEDIS tracking dashboard, large rural clinic network. Proven Novitas J-6 EDI compatibility. Confirm offline mode (critical for NE Georgia connectivity gaps) and Chronic Care IQ API.
Common requirements for both: HIPAA BAA · Commure Ambient integration · Chronic Care IQ API · Novitas J-6 EDI · offline mode for rural dead zones · QMB billing flag at intake
Commure Stack — Sits On Top of EHR
Commure Ambient AI ($100/provider/mo)
Ambient scribing during all encounters. CPT coding suggestions validated by NP. Note drafted before patient exits. Reduces per-visit documentation from ~12 min to under 3 min. NP validates every note.
Commure RCM (4% of net collections)
Charge capture → coding review → Novitas J-6 submission → ERA reconciliation → denial management. QMB coinsurance billing suppressed automatically. Scheduling bundled at no additional cost.
RPM & Care Management Platforms
Tenovi 4G cellular devices · Chronic Care IQ CCM/APCM platform
Tenovi RPM — $55 COGS/enrolled/month
4G cellular hub (no WiFi required) + BP cuff + weight scale + SpO2 + glucose. Auto-uploads daily. Alert thresholds: BP ≥180/110, weight gain ≥2 lbs/24h (CHF), SpO2 <88% → same-day coordinator contact. Server logs = 99454 billing audit trail.
Chronic Care IQ — $6/enrolled member/month
CCM/APCM panel management, care plan templates, auto-time log from coordinator activity (primary OIG audit defense), HEDIS gap tracking, monthly billing-ready documentation. EHR API integration.
Bamboo Health PatientPing — $1,500/month portfolio
ADT feeds from NGHS and Stephens County Hospital. When a FIRARA-enrolled member is discharged, care coordinator is notified within 24 hours — initiating the TOC billing window (99495/99496).
Fiber primary + cellular LTE failover. Sub-30-second automatic switchover. Clinical VLAN isolated from guest WiFi. EHR offline mode required. Fiber 4–8 week install lead time — order during buildout.
Klara: HIPAA-compliant SMS check-in, appointment reminders, care gap outreach. Doxy.me Pro + Zoom for Healthcare: NP telehealth supervision. All HIPAA BAAs in place before go-live.
Stage 5 · Operations & Business Processes · Section 5.5
Community Partnerships — Enrollment Channels & Clinical Integration
Enrollment in rural NE Georgia runs on trust, not marketing spend. Four primary enrollment channels, three clinical integration partners, and NGHS as the strategic anchor for the entire portfolio.
Warm referral sources · trust is the enrollment currency in rural NE Georgia
⛪
Faith Organizations (Highest ROI)
Fixed clinic within 15–30 min drive. Pastor trust eliminates cold outreach entirely. One Sunday bulletin announcement drives more enrollments than a month of digital advertising. NE Georgia counties have dense faith community networks — Habersham County alone has 60+ active congregations with FFS-age members.
Action: Secure 3 anchor church agreements in Habersham County before Clinic 1 opens · Offer free Annual Wellness Visit as enrollment introduction
🏥
NGHS Hospital Discharge Teams
Patients leaving NGMC Habersham, NGMC Lumpkin, or Stephens County Hospital without a PCP are the highest-priority TOC targets. Newly motivated, unattributed, within the 30-day readmission window — urgency is mutual. Bamboo PatientPing ADT feed automates the notification. The hospital's readmission penalty incentive aligns with our TOC billing revenue.
Action: Schedule meetings with discharge coordinators at NGMC Habersham and Stephens County Hospital before launch · Demonstrate TOC billing and readmit reduction value proposition
🏠
Senior Living Communities
Independent living, assisted living, and memory care facilities in each county. Facility directors are enrollment partners — they want reliable nearby primary care for residents. FFS members in senior communities are dense, transport-accessible (van stops at facility), and high-CCM-eligible.
Action: Identify 2–3 senior communities in Habersham and Lumpkin counties with FFS-majority residents · Propose scheduled clinic appointment slots
🚐
NEMT Providers (Reciprocal Referral)
Non-Emergency Medical Transport drivers already know which rural members are mobility-limited and FFS-enrolled. Reciprocal referral: we refer members needing specialist transport; they refer members needing a PCP. Zero cost, natural alignment. Informal enrollment channel into the hardest-to-reach segment.
Action: Contact NEMT operators in Habersham, Lumpkin, Stephens counties before launch · Build referral protocol into member intake workflow
Clinical Integration Partners
Partners that extend clinical reach without adding headcount
🏨
Skilled Nursing Facilities (SNFs)
TOC alignment: patients transitioning from SNF to home need a PCP immediately. FIRARA provides care continuity and reduces readmissions; the SNF benefits from improved CMS quality scores. Mutual financial incentive — formal warm handoff protocol pre-launch.
Target: SNFs in Habersham, Lumpkin, Stephens · warm handoff protocol before Clinic 1 opens
🏡
Home Health Agencies (Non-MA FFS Only)
FFS home health agencies see members between clinic visits. Complementary, not competitive. Joint RPM identification: they flag members with deteriorating vitals at home; we respond as PCP of record. Avoid MA-contracted agencies — misaligned incentives.
Confirm: non-MA contracted agencies only · shared member communication protocol
💊
Local Independent Pharmacies
Polypharmacy management is a chronic disease crisis in NE Georgia. Pharmacist-led Medication Therapy Management (MTM) is billable under Medicare Part D. Referral partnership: we identify polypharmacy cases; pharmacy conducts MTM; we close the loop in the CCM care plan. Target independent pharmacies — not chains.
Target: independent pharmacies in each clinic county
CMS Attribution Strategy & NGHS Partnership
Win and keep FFS attribution · NGHS as strategic anchor across the portfolio
Attribution wins: AWV (G0438/G0439) is the most powerful single attribution claim — establishes FIRARA as PCP of record. CCM/APCM monthly billing reinforces attribution every month between visits. Together: very difficult for a competing provider to dislodge.
NGHS as strategic anchor: NGHS has every financial incentive to reduce readmissions and ER overutilization. FIRARA reduces both. ADT feed via Bamboo PatientPing enables NGHS-FIRARA care coordination across all 10 counties. Formal referral agreement with NGHS is the highest-value pre-launch partnership activity.
Watch for: ACO-affiliated PCPs competing for FFS attribution. Monitor ACO presence by county at each clinic launch. Our retention tool is physical presence, trust, and transport access. Monitor FFS-to-MA conversion rate annually — each conversion shrinks the addressable pool.
Stage 5 · Operations · Summary & Investment Book Close
Stage 5 Summary — & The Investment Case
Operations framework complete. Five stages of analysis — the model is validated, the market is defined, the numbers are grounded. Here is what remains before capital raise, and the case in full.
∑All 5 Stages Complete Investment Book v2.0
8–12
Target visits/day per clinic · AI-enabled NP throughput
6
Hiring sequence steps · NP first, driver last · order is non-negotiable
Anchor faith partners needed pre-launch · Habersham County
Mo 2
EHR selection deadline · before PECOS enrollment finalizes
Stage 5 Chapter Recap
Six sections · what was established
5.1HR — 6-role pre-launch hiring sequence (NP first, driver last). KPIs by role. Per-clinic clinical team ~$380–420K/yr loaded. Commure RCM at 4% of collections at launch — in-house option at Series A. Per-diem LPN backup pool.
5.2Transport — Van is logistics only (member pickup/return). Fixed clinic delivers all care. AM pickup → clinic hours → PM return. 7:30 AM daily huddle (NP + LPN teleconference) is the highest-value daily operational habit. Samsara fleet tracking + rental standby within 2 hours.
5.3Clinical Ops — 5-step visit flow (Klara check-in → AI intake → NP exam → care plan → same-day claim). CCM/APCM/RPM monthly checklists. Escalation decision tree (LPN→NP→MD→911). TOC protocol via Bamboo PatientPing. HEDIS and CMMI documentation targets.
5.4Systems — EHR final two candidates (Athelas AIR / Athenahealth). Commure Ambient + RCM. Chronic Care IQ. Tenovi RPM. Bamboo PatientPing. Klara / Doxy.me. Rippling / Samsara / Compliancy Group. All integrated end-to-end, all HIPAA BAA in place.
5.5Partnerships — Faith organizations (highest ROI channel). NGHS hospital discharge teams (TOC pipeline via ADT). Senior living communities. NEMT reciprocal referral. SNFs, home health, independent pharmacies. CMS attribution via AWV + CCM monthly.
Master Open Items — Before Capital Raise
⚖️
Healthcare Attorney — Entity Formation Package
MSO (Delaware) + Clinical Entity (GA), MSA draft + FMV opinion, Nurse Protocol Agreement language (telehealth supervision clause), Stark/AKS physician structure analysis, GA CON exemption confirmation for fixed-clinic primary care. Estimated: $15–25K, 4–6 weeks.
💰
CPA / Financial Model Validation
Validate Stage 3 P&L, confirm PMPM assumptions, GAAP depreciation schedule, QMB write-off modeling, and build formal investor-grade financial model with sensitivity analysis. Required before any investor meeting. Open the financial model HTML for live scenario calculations.
🏷️
Brand Name Selection
Test 3 finalist names with community members in Habersham County. Confirm domain availability, USPTO trademark clearance, and GA entity name availability. Unblocks clinic signage, van wrap, visual deliverables, and marketing materials.
💻
EHR Selection (by Month 2)
Demo Athelas AIR vs Athenahealth. Confirm CCM time-tracking with Chronic Care IQ API, offline mode for NE GA rural dead zones, Novitas J-6 EDI, Commure API compatibility, and HIPAA BAA. Must be contracted and live before PECOS enrollment finalizes.
The FIRARA Investment Case — In Full
The market: 44,523 confirmed Medicare FFS members across HPSA-designated NE Georgia counties. Rural seniors averaging 1.4 PCP visits per year. 24% have no established primary care provider. The problem is structural and not being solved by traditional clinic economics.
The model: Fixed-clinic primary care + member transport + CCM/APCM/RPM. The fixed clinic solves the access problem. Transport removes the last barrier. CCM/APCM/RPM converts one-time visits into ~$239/member/month in recurring revenue at maturity (M18 ramp target). AI-enabled NP throughput of 8–12 visits/day. Per-clinic EBITDA positive at Month 8. 10 clinics, 10 counties, 3-year rollout.
The return: $2.5M Seed raise. Portfolio EBITDA breakeven Year 2. Base case (25% pen · 18-mo ramp · 10 clinics): ~8,809 enrolled at Y4/Y5 maturity · ~$239 blended PMPM · EBITDA ~$12.5M Y5 · $2.5M Seed → $50–63M exit · 6–8× investor return · valuation at 4–5× EBITDA or 1.2× revenue. Series B waived if Y2 working capital ≥$1M. At 400 enrolled members, $3.36M/year in documented CMS savings qualifies for CMMI Innovation Award — non-dilutive expansion capital.
Why now: GA 2024 APRN scope expansion, 2026 CMS APCM and 99445 RPM code additions, NE Georgia HMO penetration below 4%, and 44,523 FFS members uncontested — all create a window for a fixed-clinic, FFS-native, for-profit operator to claim attribution before the market consolidates. The HPSA moat is real. The community trust latency is real. Both are very difficult to replicate once lost.
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