Grove PACE · A live demo
From referral
to revenue.
PACE is the most operationally complex care model in American healthcare. Today, programs run on five vendors and Excel. Grove PACE is the operating system that connects them — with one AI thread running through every workflow.
Let me show you a single life moving through it.
MJ
Mary Johnson
Background
Date of birthMarch 4, 1947
LivesAlone · 2BR apt
FamilyDaughter Ruth (weekly)
InsuranceMedicare + Medicaid
Diagnoses (HCC)
CHF
Type 2 Diabetes
CKD Stage 4
Early Dementia
OA · Knees
Social context
Widowed (3y)
Mt. Olive Baptist
Limited transport
Recent ED visit
Act 1 · CRM · Tuesday, 9:02 AM
A broker calls. Mary becomes a lead.
PACE doesn't have a marketing engine. It has brokers, hospital partners, community events, and walk-ins. Today, that pipeline lives in spreadsheets and lost emails. Watch what happens in Grove PACE the moment Sandra Hoffman makes the call.
Sandra Hoffman, a licensed insurance broker at Sunshine Benefits, just spoke with Mary's daughter Ruth. Mary fell at home last week, was hospitalized for 3 days for CHF decompensation, and Ruth is worried she can't manage alone anymore. Sandra refers Mary to Grove PACE at 9:02am. The 1-hour broker SLA timer starts.
Mary Johnson
78 · Harbor District · Added today via Sunshine Benefits (broker)
New lead
Broker — Sunshine Benefits
SLA: 42 min remaining
4 automations fired
Overview
Activity
Documents
Assessments
Contact details
DOBMar 4, 1947 (age 78)
Phone(415) 555-0182
Address412 Harbor St, Apt 3B
DaughterRuth Johnson · weekly
Assigned repK. Lin (auto-assigned)
SiteHarbor District
Medicare✓ Verified · 1EG4-TE5-MK72
Medicaid✓ Verified · CA dual-eligible
Lead source & broker attribution
Source typeBroker referral
BrokerSandra Hoffman 🏆
AgencySunshine Benefits LLC
Referral dateToday, 9:02am
SLA status42 min to first contact
Commission tier$1,400 on enrollment
Trigger contextRecent fall + CHF hosp.
Duplicate check✓ No duplicates found
Automations that fired on save: Territory rep K. Lin assigned · CMS Medicare API lookup completed · State Medicaid lookup completed · Service area validated · Duplicate detection ran · 1-hour broker SLA timer started · Sandra Hoffman commission tracker initiated · Sunshine Benefits referral counter +1.
Talking point
"Today, this is 6 phone calls and 11 spreadsheet updates across 4 systems. With Grove PACE — one save, 8 things happen automatically. Sandra gets paid the day Mary enrolls. The territory rep gets pinged. Eligibility verifies in 90 seconds via CMS API. This is where PACE acquisition stops bleeding."
Act 2 · CRM · 14 days later
Eight steps. One state machine.
From first contact to DHCS approval, every PACE enrollment moves through a regulated sequence. Most orgs lose 5 business days to handoff errors. Grove PACE runs the whole pipeline as a single state machine — every step emits events, every SLA is tracked, every handoff is automatic.
Two weeks have passed. Mary has been called by K. Lin (within 38 min of referral), met with the enrollment specialist, completed Level of Care evaluation, signed the home safety eval, and her enrollment package is at DHCS. Today, the approval comes through. One click triggers six downstream system handoffs.
Mary's enrollment lifecycle
Lead → Enrolled · 14 days · 0 manual handoffs
✓
1 · Lead captured
Sunshine Benefits broker referral · Sandra Hoffman · 9:02 AM, 14 days ago
emits: crm.prospect.createdauto: territory rep K. Lin assigned
✓
2 · Eligibility verification
CMS Medicare API + state Medicaid lookup. Service area boundary validated. Dual-eligible confirmed in 87 seconds.
auto: CMS API lookupemits: eligibility.confirmed
✓
3 · Outreach & engagement
K. Lin called Mary at 9:40 AM (38 min after referral, beating 1-hour SLA). Daughter Ruth joined call. Home visit scheduled for Day 3.
auto: call logged via Genesys
✓
4 · Level of Care & Home Safety Eval
RN home visit Day 3. LOC and HSE forms signed via integrated DocuSign. Mary qualifies — meets nursing home level of care criteria per CA DHCS.
auto: forms routed for signatureemits: assessment.loc.signed
✓
5 · Medical records retrieval
3 years of records pulled from Harbor General (3.2 days avg) and Mary's PCP via Credo Health. Hospital discharge summary parsed.
auto: Credo Health requestemits: records.received
✓
6 · Enrollment meeting
Mary, Ruth, and the Center Director met at Harbor District site Day 8. Mary toured the day center, met staff, signed enrollment agreement.
auto: family welcome packet sent
✓
7 · DHCS submission
Enrollment package compiled (LOC, HSE, agreement, eligibility). Submitted to CA DHCS Day 9. Tracking active.
auto: package compiled + submittedemits: dhcs.submission.sent
8
8 · DHCS approval → enrolled
Approved today, 11:14 AM. Mary is now Grove PACE participant #87. One click fires 6 events.
emits: enrollment.participant.enrolled
SLA performance
Broker → first contact38 min ✓
Lead → eligibility87 sec ✓
Eligibility → assessment3 days ✓
Assessment → DHCS5 days ✓
DHCS turnaround5 days
Total enrollment14 days
On enrollment, 6 events fire
→ Clinical module
Mary's chart created · IDT scheduled · care plan template loaded
→ Health Plan
Capitation tracking begins · RAF baseline calculated · MMR matching prepared
→ Transportation
Address geocoded · ride eligibility set · church transport flagged
→ Family portal
Ruth invited as authorized contact
→ Quality
New enrollee compliance clock starts · 30-day initial care plan deadline
→ Broker payment
Sandra's $1,400 commission scheduled (Stripe, 5-day pay)
Talking point
"This is the data plumbing. It's not glamorous — but it's the moat. When clinical, billing, transport, and quality all run on one schema, every downstream feature gets smarter. The competition has 5 vendors talking to each other badly. We have one operating system."
Act 3 · Clinical · Day 16 · Comprehensive Assessment
In one 47-minute conversation,
eight extractors do an hour and a half of work.
In PACE, the comprehensive assessment is where the team learns who Mary is. Today it takes 60 minutes — half of which is the assessor typing while making eye contact (the split-brain tax). With ambient capture, Karen puts the tablet face-down on the kitchen table. They just talk. Eight extractors listen — each with its own job, its own graduation track. By the end, the form is 85% populated, and Mary's What Matters Most is captured in her own voice.
From Act 2: Mary's enrollment data, intake forms, and Ruth's contact info are loaded. Today on Day 16, the SW visits Mary at home for the comprehensive assessment. One ambient session opens. Eight extractors compose against the same shared transcript.
Ambient session · Comprehensive Assessment · Mary Johnson
Day 16 · Karen Davis, MSW · Mary's kitchen, 412 Harbor St · Deepgram nova-3-medical · diarized live
Live transcript
KD
Tell me about Walter.
MJ
Fifty-one years. He was a teacher, like me. Passed three years ago last month. This apartment was where we lived together — I'm not leaving it unless I have to.
WMM Narrative
GDS-15
KD
What's a typical morning like for you?
MJ
I do my own bathing. I dress myself. Some mornings my knees are stiff, so I sit on the edge of the tub. Ruth takes me grocery shopping Saturdays — I can't drive anymore. I manage my own money but the bills are getting harder.
Katz ADL
Lawton IADL
KD
I'm going to say three words and ask you to remember them. Apple, Penny, Table. Now could you draw a clock face showing eleven‑ten?
MJ
[draws]
KD
Numbers placed correctly, hands at eleven and two. Mary, what were the three words I gave you?
MJ
Apple. Penny. Table.
MoCA
MJ
I fell in the bathroom about three weeks ago. I was getting up from the toilet and my legs gave out. Caught myself on the towel bar.
STEADI Falls
MJ
My pills are on the kitchen counter. Ruth fills my organizer every Sunday. Sometimes I forget the evening dose.
Beers Review
MNA-SF
MJ
I do not want to die in a hospital. I want to be home, with Ruth, when it's time.
WMM Narrative
Assessment form · auto-populating
WMM Narrative
89%
"Stay in my own home. Don't leave the apartment Walter and I shared. Don't burden Ruth. Keep going to Mt. Olive on Sundays. Cook my own meals when I have energy. Do not die in a hospital — be home with Ruth when it's time."
Ambient
MoCA
91%
22 / 30 · mild cognitive impairment range · clock-draw correct · 3/5 delayed recall · attention preserved · executive: mild deficit · consistent with early dementia per intake
Suggest
GDS-15
94%
8 / 15 · mild depression range · grief-rooted (3-yr widowhood, anniversary recent) · social anchor preserved (Mt. Olive Baptist)
Autopilot
Katz ADL · Lawton IADL
97%
Katz 6/6 independent · Lawton 5/8 (shopping w/help, can't drive, finance difficulty) · borderline IADL decline
Autopilot
STEADI Falls Risk
95%
6 · increased risk · history of falling: yes (3 wks ago) · fear of falling: yes · feels unsteady standing · uses towel bar for support · CDC algorithm flags PT referral
Autopilot
Beers Polypharmacy Review
88%
11 medications · 2 potentially inappropriate per Beers Criteria · 1 anticholinergic burden flag · evening dose adherence concern · daughter Ruth fills weekly · verify drug list with bottle photos at OT visit
Suggest
Extractors armed
WMM Narrative
Suggest
MoCA
Suggest
GDS-15
Autopilot
Katz ADL
Autopilot
Lawton IADL
Suggest
STEADI Falls Risk
Autopilot
MNA-SF
Suggest
Beers Polypharmacy
Suggest
60→35
Minutes per assessment
25 minutes back per participant.
Better presence, better rapport, better assessment.
Better presence, better rapport, better assessment.
Documenting-while-asking goes from 20–25 minutes to zero — Karen reviews the auto-populated form for 4 minutes at the end and signs. The deeper win isn't time. It's that Karen made eye contact with Mary the entire conversation. Rapport went up. The clinical interpretation was sharper because Karen had cognitive bandwidth for it instead of form navigation.
Mary's What Matters Most · in her own words
Captured by the WMM Narrative extractor · suggest stage · 89% approval · Karen reviews and signs
MJ
Mary Johnson, in her own voice
Composed from 9 transcript segments by the WMM Narrative extractor · approved by Karen, MSW
Suggest · 89%
"I taught fifth grade for 38 years. Walter and I were married 51. I lost him three years ago last month. I want to stay in my own home. That apartment is the last place we lived together and I am not leaving it unless I have to. I don't want to be a burden on Ruth. I want to keep going to Mt. Olive on Sundays. That's where my people are. I'd rather skip a doctor's appointment than miss Bible study. I know my heart isn't strong. I take my pills. Sometimes I forget. I would like to cook for myself when I have the energy — Walter's mother taught me, and it's how I remember her. I do not want to die in a hospital. I want to be home, with Ruth, when it's time."
— composed from a 47-minute conversation, Day 16, in Mary's kitchen · audio playback available at every passage
From Mary's words → six care goals
Auto-derived from the WMM narrative · all six populated as AmbientField values · Karen + IDT confirm before activation
Goal 1 · Highest priority
Stay in her home
Aging-in-place plan: PCA support 3x/wk, home safety eval ✓, RPM enrolled, fall-prevention PT, OT home assessment.
Goal 2 · Identity
Mt. Olive Baptist Church
Church transport priority routing — Sunday 9 AM, Wednesday 6 PM. Day-center attendance respects Sunday/Wednesday.
Goal 3 · Avoidance
No hospital admissions
Tight CHF home monitoring, blister-pack adherence, Ruth set up for warning signs, advance directives within 90 days.
Goal 4 · Memory & meaning
Cook her own meals
Dietitian builds plan AROUND Walter's mother's recipes — Southern cooking adapted for cardiac/diabetic/renal. Not "compliance" — preservation.
Goal 5 · Family
Don't burden Ruth
PCA + day center reduces Ruth's caregiving load. Family portal keeps Ruth informed without pulling her in for every issue.
Goal 6 · End of life
Die at home, with Ruth
POLST and advance directives queued for Day 90. Hospice partnership pre-identified. Ruth designated decision-maker.
Talking point
"This is the architectural moat made visible. Eight extractors — one shared audio stream — each on its own graduation track. Katz ADL at 98% on autopilot. STEADI Falls Risk at 95% on autopilot. WMM Narrative at 89% still in Suggest, because clinical voice matters and Karen needs to confirm. MoCA still in Suggest because cognitive judgment is nuanced. Beers Polypharmacy in Suggest because deprescribing is the clinician's call. Every input field in Grove inherits this primitive — “you can type or you can talk.” The competitor that wants to ship the comprehensive assessment in PACE has to build all eight extractors. We've already built the architecture that lets us add the ninth in a week."
Act 4 · Clinical · Day 18 · Initial Care Plan
Eleven specialists. One care plan.
Federal regulation §460.106 requires Mary's interdisciplinary team to build her initial care plan within 30 days of enrollment. Eleven disciplines must agree. Today, that's a 90-minute meeting where half the team scrambles for context. Watch what happens when Grove's IDT agents do the prep.
From Act 3: Mary's WMM is loaded as the north star. The agents read it first — before they read her chart. Her words frame every recommendation that follows.
How this works: When Mary's care plan session is initiated, 11 AI agents — one per IDT discipline — review her WMM, medical history, and intake data simultaneously. They collaborate, challenge each other when clinical evidence conflicts, and produce a draft consensus. Any human IDT member can override any agent recommendation. The humans remain the final decision-makers.
IDT Agent Session · Mary Johnson · Initial care plan
Started 9:14 AM · Consensus reached 9:23 AM · 11 agents
Primary Care
PCP Agent
Medicine, chronic disease, orders
Nursing
RN Agent
Care coordination, monitoring
Social Work
SW Agent
Psychosocial, resources, safety
Physical Therapy
PT Agent
Function, mobility, fall prevention
Occupational Therapy
OT Agent
ADLs, adaptive equipment, home
Dietitian
Dietitian Agent
Nutrition, cultural meal planning
Pharmacy
Pharmacy Agent
Med reconciliation, adherence
Recreation
Rec Agent
Activities, group fit, engagement
Personal Care
PCA Agent
ADL assistance, home support
Transportation
Transport Agent
Ride scheduling, logistics
Center Manager
Center Agent
Day center attendance, program
PCP
PCP Agent · Reviewed records
Mary has CHF (EF 35%, NYHA Class II), Type 2 DM (HbA1c 8.4 at admission), CKD Stage 4 (eGFR 28), early dementia (MoCA 22), and bilateral knee OA. Recent CHF decompensation likely triggered by Lasix non-adherence + dietary sodium. Recommend: initiate SGLT2 inhibitor (cardiac + renal protection), discontinue Meloxicam (NSAID + CKD = bad combo, fall risk), switch to Acetaminophen 500mg TID for knee pain, optimize Lasix to AM-only dosing.
SW
SW Agent · Psychosocial assessment
Mary is widowed 3 years (husband Walter, also a teacher — strong identity tied to that). Daughter Ruth is engaged but lives 40 min away. Mt. Olive Baptist Church is her primary social anchor — Wednesday Bible study, Sunday service, choir. PHQ-9 at intake: 8 (mild depression — likely grief-rooted). Critical to preserve church engagement. Recommend: SW home visit q2 weeks, church transport priority routing, family education on CHF warning signs for Ruth.
PT
PT Agent · Functional baseline
Berg Balance Score 38/56 (moderate fall risk). TUG 18 sec (high risk). Quad strength 3/5 bilateral. Agreed on Meloxicam discontinuation — appropriate given CKD and fall risk. Pain management adjustment noted. PT plan: 2x/week initially, focus on quad strengthening, balance, sit-to-stand. Hold first PT session until Day 22 after pain management is stabilized on Acetaminophen.
Diet
Dietitian Agent · Culturally informed plan
Mary is African American with Southern food traditions. Cooks for self when energy permits. Cardiac + diabetic + renal adaptation needed (challenging triple constraint with CKD 4). Plan: (1) Reduce sodium target ≤2g/day (challenging — collards, ham hocks are anchors), substitute smoked turkey for pork, citrus + herbs for flavor; (2) Modify cornbread — buttermilk/whole wheat blend, less fat; (3) Sweet potato preferred over white potato (lower glycemic, K-controlled portions); (4) Small portions of fried foods only if baked-substitute possible; (5) Ruth shops for her — meal delivery enrolled for non-day-center days.
Pharm
Pharmacy Agent · Med reconciliation
Currently on 11 medications (polypharmacy concern). Discharge med list reconciled. Concerning: 2 missed Lasix doses in past week (per Ruth). Likely cause of recent CHF flare. Recommend: blister pack medication organizer (weekly fill), AM-only Lasix dosing per PCP, daughter Ruth set up as Rx pickup contact, pharmacy auto-refill enabled, eliminate Meloxicam, add SGLT2 inhibitor (Empagliflozin 10mg QD — also renal-protective in CKD 4 if eGFR ≥20).
Rec
Rec Agent · Engagement plan
Day center attendance schedule: M/W/F (3 days/week initially). Recommend gentle exercise group (chair yoga), spiritual reflection group (aligns with church identity), and weekly memory care group given early dementia. Ruth confirmed Mary used to enjoy choir — explore center music program for fit.
Trans
Transport Agent · Logistics
Address geocoded: 412 Harbor St #3B. Apartment building has elevator (verified). Day center pickup window: 7:45–8:00 AM M/W/F. Church transport priority added per SW request — Sunday 9 AM pickup, Wednesday 6 PM pickup. Routes assigned to driver Anthony (knows Harbor District, 4-yr tenure).
✓
Consensus reached — care plan ready for human IDT review
11 of 11 agents agree. Key resolutions: (1) Meloxicam → Acetaminophen — PCP/PT/Pharm cross-validated · (2) SGLT2i added (Empagliflozin) — PCP/Pharm verified safe at eGFR 28 · (3) PT delayed to Day 22 post-stabilization · (4) Culturally adapted soul-food meal plan · (5) Mt. Olive Baptist transport priority · (6) Blister pack with weekly pharmacy delivery · (7) SW home visit q2wk · (8) Day center M/W/F · (9) Ruth enrolled as authorized contact + Rx pickup. Ready for human IDT signatures. Estimated meeting time: 12 minutes (vs. typical 90).
Talking point
"This is the moment generic AI scribes can't follow us into. The dietitian agent knows that smoked turkey replaces pork in Southern cooking for sodium reduction. The pharmacy agent knows Empagliflozin is safe at eGFR 28 but not at 18. The SW agent knows that for a Black widowed schoolteacher, Mt. Olive Baptist isn't optional — it's identity. Vertical depth. PACE-specific knowledge work. This is why Epic and Notably can't ship this."
Act 5 · Clinical · 4 months in · A Tuesday morning
A panel of 87. Mary at the top.
Mary has been a Grove PACE participant for 4 months. Today, her PCP — Dr. Maria Chen — opens her brief at 7:32 AM. She has 12 participants on her schedule. Before she's even sipped her coffee, Grove has already triaged her panel, surfaced the 3 deteriorations, and drafted her pre-encounter brief for the visit that matters most. Mary's.
From Act 4: Mary's care plan, WMM, dx list, med list, and Ruth's contact info are all live. Mary's home BP cuff (RPM-enrolled at IDT) reported a 3-lb weight gain over 10 days. The pharmacy fill data shows 2 missed Lasix doses. Grove correlated these signals at 2 AM.
Good morning, Dr. Chen
Brief generated 7:32 AM
Today is 12 participants across 6 hours. Three need your attention before clinic — Mary Johnson (weight up 3 lbs, 2 missed Lasix doses, daughter called twice), Mr. Nguyen (nutrition reassessment 6 days overdue), and Mrs. Patel (fall risk re-eval due today). Your AP-2025-019 expedited appeal has a CMS deadline of tomorrow 5 PM. Yesterday's IDT decided to increase Mr. Okafor's PT frequency to 3x/week — first session today at 2 PM. You left the center at 5:12 PM yesterday. Welcome back.
Deterioration · 3
2 min ago
Mary Johnson
Wt +3 lb / 10d · 2 missed Lasix · Ruth called 2x
78
↑ 24 / 7d
Mr. Nguyen
Nutrition reassess 6d overdue · 3 shake refusals
61
↑ 8 / 7d
Mrs. Patel
Fall risk re-eval due today · 1 near-miss reported
54
→ stable
Population view · Readmission Risk Score
87 participants · 93-point composite · Auto-calculated
66–93
Critical
Same-day IDT escalation + SW outreach + Grove alert
2 participants
38–65
High
IDT huddle within 48 hours + SW outreach
7 participants
19–37
Moderate
Care plan review within 7 days
22 participants
0–18
Low
Routine monitoring · standard care plan cycle
56 participants
Top 5 risk-stratified participants
Click any row to open detail · Mary is your Critical case today
| Participant | Component scores (max 93) | Total | Tier | Trend | Required action |
|---|---|---|---|---|---|
| Mary Johnson CHF · DM2 · CKD4 · Dementia |
LACE 14SDOH 9Med 8BH 4Func 7CDB 8Care 5Nutr 3 |
78 | Critical | ↑ +24 | Same-day IDT |
| Earl Washington CHF · DM2 · HTN |
LACE 12SDOH 7Med 6BH 3Func 6CDB 7Care 4Nutr 2 |
67 | Critical | ↑ +8 | Same-day IDT |
| Alice Nkrumah DM2 · HTN · CHF · OA |
LACE 8SDOH 11Med 6BH 2Func 6CDB 5Care 3Nutr 1 |
42 | High | ↑ +5 | 48hr IDT |
| Margaret Chen COPD · Dementia |
LACE 6SDOH 6Med 5BH 9Func 5CDB 6Care 3Nutr 5 |
45 | High | → stable | 48hr IDT |
| Bernard Kim HTN · OA · CKD3 |
LACE 4SDOH 3Med 3BH 0Func 3CDB 3Care 1Nutr 0 |
17 | Moderate | ↓ −3 | 7-day review |
Mary's pre-encounter brief · drafted by Grove · 7:32 AM
Ambient mode ready · 7 extractors armed · review and edit before signing
Why Mary's at the top of your day
Mary Johnson, 78, has CHF (EF 35%, NYHA II), DM2, CKD Stage 4, early dementia, OA. Enrolled 4 months ago. Weight up 3 lb in 10 days via home BP cuff (RPM). Pharmacy fill data shows 2 missed Lasix doses in past week. Daughter Ruth has called twice in 48 hrs reporting bilateral leg swelling and shortness of breath when walking from bedroom to bathroom. RRS jumped from 54 → 78 over 7 days.
Likely diagnosis (suggested · clinician confirms)
Early CHF decompensation from medication non-adherence, likely compounded by emotional stress (3-yr widowhood anniversary was 6 days ago — Grove flagged this from Mary's intake history). NOT acute MI or new-onset, given vitals trend.
What I would explore in the room
(1) Why the missed doses — depression flaring? cognition? confusing pill organizer? (2) Lower extremity exam, JVD, lung bases. (3) Re-engage Ruth on home med routine. (4) Consider PHQ-9 today given anniversary timing. SW Agent is suggesting a home visit this week — pre-drafted in your inbox.
Orders Grove will draft if you confirm
CMP + BNP + UA · increase Lasix to 60mg AM (from 40mg) · add SW visit this week · schedule Pharm med-routine review with blister pack reorder · update care plan with grief-aware narrative.
The Moat · The Compounding Loop
Autonomy is earned. Demotion is automatic.
No feature ships on autopilot. Every Grove feature earns autonomy by demonstrating measured agreement with clinician behavior. Every override is a training signal. Every graduation is a human decision. When drift appears, features demote before they damage.
Stage 1
Observe
Log every clinician action. Collect data. No AI output yet.
5
features
Stage 2
Shadow
AI runs silently. Clinician never sees. Agreement measured.
8
features
Stage 3
Suggest
AI proposes. Clinician adopts, adapts, or overrides.
14
features
Stage 4
Autopilot
AI acts. Clinician is notified. Override always available.
3
features
Talking point
"This is why clinicians trust Grove where they don't trust other AI vendors. Pre-encounter briefs spent 6 months in Shadow before they were allowed to Suggest. The judgment log measures every adopt, adapt, and override — the org gets an honest picture of AI use, and the model gets training signal. Every month, the data flywheel widens our lead. This is the compounding moat."
Act 6 · Clinical · Same Tuesday · 7:34 AM · Before clinic
Dr. Chen needs to think. She opens Grove.
Grove isn't only a workflow tool — it's a clinical thinking partner. Dr. Chen has 20 minutes before her first patient. Mary's deterioration alert is unusual: weight up 3 lb, two missed Lasix doses, and the 3-year widowhood anniversary was last week. She wants to think through this with someone who knows everything about Mary. So she opens Grove.
From all prior acts: Grove has read Mary's WMM, her care plan, every IDT note, every encounter, every RPM data point, every pharmacy fill, every transport log, and §460 regulations. When Dr. Chen asks a question, Grove answers like the colleague who's read every chart.
How this works: Grove operates in three modes — Clinical (patient care reasoning), Research (evidence and best practices, with citations), Coaching (professional growth, documentation habits). Provider-first, always. Speaks when spoken to. Cites §460 specifically. Never directs — only drafts, suggests, prepares. And every interaction is logged in the Judgment Tracker so the team can see how AI is being used — adopted, adapted, or set aside in favor of clinician judgment.
Why this matters
Generic AI can't do this. ChatGPT doesn't know Walter died on March 27. Doesn't know Mary's PHQ-9. Doesn't know §460.140. Doesn't know Karen's home visit notes. Doesn't know Mary's exact phrasing about her apartment.
Grove does — because Grove lives where the data lives. Vertical AI built on top of a vertical operating system. The competitive moat isn't the model — it's the data plumbing under it.
Grove does — because Grove lives where the data lives. Vertical AI built on top of a vertical operating system. The competitive moat isn't the model — it's the data plumbing under it.
Three modes
Clinical · patient reasoning, care planning, clinical judgment support — currently active
Research · evidence, studies, best practices — surfaces with citations
Coaching · documentation habits, professional growth — confidential, not shared with management
Brand principle
"Speak when spoken to. Suggestions are optional. Clinicians feel Grove is their tool — not management's eye."
High independent-judgment rates in the Judgment Tracker are a sign of clinical strength, not non-compliance.
High independent-judgment rates in the Judgment Tracker are a sign of clinical strength, not non-compliance.
Talking point
"This is what trust-with-AI looks like in healthcare. Grove isn't autocompleting a SOAP note — it's the colleague who's read every chart, knows every reg, and remembers Mary's husband's name. Notice what Grove didn't do: it didn't tell Dr. Chen what to do. It surfaced context, offered three considerations, and put the decision back in her hands. That's why clinicians actually use it."
Act 7 · Quality · Same Tuesday · 11:14 AM
Every action auto-audited.
Mary's clinic visit is over. Her exam is signed, her labs are ordered, the SW visit is scheduled. Right now, in the background, Grove's compliance engine is logging every action against 42 CFR Part 460. CMS audits happen every 3 years and they're existential. Most PACE orgs prepare with Excel. Grove PACE makes audit-ready a continuous state.
From Acts 4 & 5: Mary's IDT signatures, care plan, encounter notes, RPM data, and orders all flow into the audit trail automatically. Nothing is "documented later." Documentation IS the workflow.
CMS audit readiness
87%
↑ +6% this quarter
Days to next audit
99
Jul 14, 2026
Pre-audit checklist
41 / 48
7 remaining
Open CAPAs
4
1 at risk
42 CFR Part 460 · Mary's compliance footprint
Auto-tracked from her enrollment forward
| Citation | Requirement | Mary's status |
|---|---|---|
| §460.106 | Initial care plan within 30 days of enrollment | ✓ Day 18 |
| §460.136 | IDT must include all 11 disciplines | ✓ 11/11 signed |
| §460.140 | QAPI signal logged for clinical events | ✓ Auto-logged |
| §460.156 | Comprehensive assessment every 6 months | Due Apr 14 |
| §460.98 | Transportation eligibility documented | ✓ Verified |
| §460.72 | Incident reporting (none required this period) | ✓ N/A |
Pre-audit checklist progress
CMS triannual audit · 99 days out
Grievance log updated✓ Complete
Appeals docs · §460.104✓ Complete
IDT minutes archived (12 mo)✓ Complete
SDR submissions verified✓ Complete
QAPI quarterly reportsIn progress
Care plan signature SOPCAPA-022 ⚠
Transportation §460.98 SOPSOP gap
Pattern intelligence
CAPA-022 (care plan signatures) is flagged "Repeat" issue. Grove noticed this same workflow gap in Q4 2025. Auto-routing micro-training to S. Kim, MSW before the manager has to escalate.
A real grievance · auto-managed end-to-end
Not Mary's — but representative of how Grove handles the §460.68 process
GR-2025-047 · Care Quality Grievance
Filed Apr 1, 2025 · Status: Investigating · 24 days remaining to resolution
ParticipantRobert A.
CMS reference§460.68
Filed dateApril 1, 2025
Resolution deadlineApril 30, 2025
CategoryCare Quality
Days remaining24 days
Assigned toSarah Kim, MSW
OutcomePending
Apr 1, 10:14 AM
Grievance received and logged
Phone intake by Sarah Kim, MSW. Participant verbally informed of grievance process.
Apr 1, 11:00 AM
Acknowledgment letter sent
Auto-generated per §460.68 · within 24-hour requirement.
Apr 5
Investigation in progress
Staff interview scheduled · participant chart reviewed · CAPA-024 opened.
Talking point
"CMS audits don't fail because PACE orgs don't care — they fail because PACE orgs document in 17 places. Grove is the single source of truth. Citation auto-attached. Acknowledgment letter auto-generated. CAPA auto-tracked. Repeat patterns auto-flagged before management notices. The audit becomes a non-event."
Act 8 · Health Plan · Same Tuesday afternoon
The diagnosis becomes $3,477.
Most clinical EMRs stop at the chart. Grove PACE closes the loop to revenue. PACE is capitated — every diagnosis Mary has, properly documented, becomes captured RAF score, becomes higher monthly capitation, becomes the budget that pays for her care. Watch what happens with Mary's CKD Stage 4 diagnosis from Act 4.
From Act 4: Mary's CKD Stage 4 diagnosis was documented in the IDT consensus. From Act 5: today's lab order will refresh the eGFR. Grove's chart audit agent surfaces this as an HCC suspect for the coder. The Medical Director co-signs. The capture flows to CMS.
YTD cap revenue
$47.2M
↑ 12.4%
Avg RAF (V28 blend)
1.84
↑ from 1.78
Medical Loss Ratio
87.3%
Target ≤89%
Active HCC suspects
23
Grove-surfaced
Annualized opportunity
$218K
If all captured
HCC Command Center · Top suspects today
Grove surfaced · Coder validates · Med Director co-signs · CMS submission
Code
Participant · Condition
Evidence
Confidence
RAF Δ
Action
HCC 138
Mary Johnson
CKD Stage 4 · V28 NEW
3× eGFR < 30 (28 today, 26 mar, 29 jan) · IDT-documented · nephrology consult on file
96%
+0.289
HCC 85
Mary Johnson
CHF · current decompensation
Today's BNP, EF 35% on echo, Lasix titration · MEAT ✓
98%
+0.324
HCC 51
Mary Johnson
Dementia w/o complications · V28
MoCA 22, IDT-flagged, behavioral plan in WMM
91%
+0.302
HCC 18
P. Wilson
Diabetes w/ Renal Manif. · combined code
CKD + DM coded separately; combined yields higher RAF
93%
+0.178
HCC 55
R. Torres
Substance Use Disorder · in remission · V28
Documented in SW notes; underutilized in V28
72%
+0.213
Mary's RAF math · per-month impact
If all 3 HCCs captured this CMS year
| HCC | RAF Δ | PMPM impact | Annualized |
|---|---|---|---|
| HCC 138 · CKD 4 | +0.289 | +$429 | +$5,148 |
| HCC 85 · CHF | +0.324 | +$481 | +$5,772 |
| HCC 51 · Dementia | +0.302 | +$448 | +$5,376 |
| Total Mary | +0.915 | +$1,358 | +$16,296 |
$16,296/year for one participant from documenting what Mary already has — diagnoses confirmed by IDT in Act 4, refreshed by clinic visit in Act 5. The capture isn't extra work. It's already in the chart.
Retention watch · the decay clock
CMS resets HCCs annually. Don't let them lapse.
| Participant | HCC at risk | Days since | RAF loss |
|---|---|---|---|
| Mary Johnson | HCC 85 CHF (last yr) | 68d | −0.324 |
| A. Nkrumah | HCC 85 CHF | 62d | −0.324 |
| E. Washington | HCC 138 CKD 4 | 100d | −0.289 |
| M. Chen | HCC 37 DM w/ Comp. | 76d | −0.306 |
| B. Kim | HCC 176 Artificial Opening | 123d | −0.543 |
Mary's CHF capture from last year is decaying. Today's clinic visit refreshes it — but only if it's properly coded. Grove is queuing it for the coder right now. This is what other EMRs miss.
Talking point
"This is the part nobody else does. Most clinical EMRs stop at documentation. We close the loop to revenue. $16,296 per year per participant — for diagnoses Mary already has. Multiply by 87 participants. Multiply by 180 PACE orgs nationwide. This isn't a feature — it's an economic engine."
Close · The full picture
One operating system. One flywheel.
Mary Johnson is one person. We followed her through six modules, four months, eleven specialist agents, three HCC captures, one CMS-compliant audit trail. Today, PACE orgs do this in five vendors and Excel. Grove PACE replaces all of them.
Grove PACE · CRM
Lead intake, broker network, eligibility, enrollment workflow, DHCS submission, conversion to participant. Replaces: standalone CRM + manual broker tracking + DocuSign.
Grove PACE · Clinical
IDT agents, care plans, ambient encounters, RPM, panel surveillance, deterioration signals, judgment log, compounding loop. Replaces: legacy PACE EMR + ambient scribe + analytics tools.
Grove PACE · Quality
42 CFR Part 460, grievances, appeals, SDR, incidents, CAPA, QAPI, automated chart audits, audit prep, regulation hub. Replaces: Word/Excel + compliance consultant binders.
Grove PACE · Health Plan
Capitation tracking, RAF, HCC Command Center, MMR/MOR, claims, prior auths, MLR, RADV audit defense. Replaces: separate health plan ops vendor + Excel RAF tracking.
The Grove PACE Flywheel
A diagnosis becomes a dollar.
A dollar becomes better care.
A dollar becomes better care.
Clinical documents the diagnosis. Revenue captures the HCC. Capitation rate goes up. The org can afford better care. Better care means fewer hospitalizations. Lower hospitalizations mean lower MLR. Lower MLR means more margin to invest. One operating system. One AI thread. One flywheel.
01
Clinical
IDT documents Mary's CKD 4
02
Capture
HCC 138 surfaced & submitted
03
Revenue
+$429 PMPM cap rate
04
Reinvest
SW visits, RPM, blister pack
05
Outcome
Hospital admission averted
06
Margin
MLR drops & cycle restarts
Mary Johnson · what changed in 4 months
Concrete outcomes from one operating system
Hospital admissions
0
vs. projected 2 (CHF history)
RAF captured
2.34
↑ from 1.42 baseline
Revenue captured (Mary)
$16.3K
Annualized run-rate
Care plan adherence
94%
Dietary, meds, attendance
The Ask
PACE is a $8B market today.
$25B by 2030.
We're the platform underneath all of it.
$25B by 2030.
We're the platform underneath all of it.
Adjacent expansion: I-SNP, dual-eligible Medicare Advantage, integrated managed long-term services and supports (MLTSS). Same buyer. Same workflows. Same vertical AI.