👵🏾
Dorothy Mae Williams
74 YRS • RURAL BLACK SENIOR • MEDICARE A+B
HbA1c
9.2%
BP
158/94
ACG Risk Score
87/100
SDOH Burden
Critical
Last Visit
14 mo. ago
Insurance
Active
SDOH Factor Map — SmartScribe Auto-Detected
Real-time Z-code assignment via Compass Riley clinical reasoning engine. WellFit self-report layer validates and enriches.
Housing
Inadequate housing, no heat
Z59.0 · Z59.1
Food Security
Food insecure, rural food desert
Z59.4 · Z59.48
Transportation
No vehicle, 47 mi. from clinic
Z59.82
Cultural Competency
Faith-based community anchor
CC-FAITH · CC-MISTRUST
Health Literacy
Low literacy, spoken-word preferred
Z55.0 · Z55.8
Social Isolation
Widowed, rural, limited contact
Z60.2 · Z60.4
Atlus Engine Pipeline — Dorothy's Journey
1
ACG Risk Signal
ACG System scores Dorothy at 87/100 — high hospitalization risk, multimorbid, care coordination flag
ACG System
2
Compass Riley CDS
Clinical decision support layers SDOH context, cultural flags, and faith-community signals onto ACG output
CoT + ToT Reasoning
3
SmartScribe Codes
T+0 ICD-10 Z-code generation. Z59.0, Z59.4, Z59.82 auto-appended to encounter. Claim submitted same day.
FHIR R4 · Real-Time
4
WellFit Connects
Dorothy enrolled in food delivery, faith-community peer program, and telehealth schedule. Loop closed.
WellFit Community
Z-Code Revenue Intelligence
Auto-generated by SmartScribe · CMS 2026 compliant
| Z-Code | Determinant | DRG Impact | Status |
|---|---|---|---|
| Z59.0 | Inadequate Housing | +$412 | Auto-coded |
| Z59.4 | Food Insecurity | +$387 | Auto-coded |
| Z59.82 | Transportation Barrier | +$298 | Auto-coded |
| Z55.0 | Low Health Literacy | +$215 | Pending review |
| Z60.2 | Social Isolation | +$189 | Auto-coded |
Total Captured Revenue
$1,501 this encounter
Previously uncaptured: ACG alone cannot bill. Atlus closes the gap.
ACG System vs. Envision Atlus
Capability delta for Dorothy's care journey
Capability
ACG System
Envision Atlus
Risk Identification
✓ Population-level
✓✓ Patient + population
SDOH Detection
~ Non-clinical data input
✓ Self-report + clinical AI
Z-Code Generation
✗ Not available
✓ T+0 auto-coded
Cultural Competency
✗ Not in scope
✓ Faith, trust, language, bias
Community Connection
✗ Analytics only
✓ WellFit live referral
Revenue Capture
✗ No billing engine
✓ DRG + Z-code billing
CMS 2026 Ready
~ Partial
✓ Full compliance built-in
Cultural Competency Engine — African American Rural + Urban Populations
Atlus is the only platform that embeds cultural intelligence directly into clinical workflows — not as a checkbox, but as a reasoning layer that shapes how care is delivered to Dorothy and patients like her.
Historical Medical Mistrust
Compass Riley detects mistrust indicators — delayed care patterns, refusal history, provider avoidance — and alerts the care team with culturally sensitive engagement protocols rooted in the lived history of African American patients.
Compass Riley Flag
Faith-Community Health Bridges
WellFit maps faith community membership and routes care coordination through trusted church networks. For patients like Dorothy, the church is healthcare infrastructure. Atlus treats it as such — connecting care teams to faith leaders who can support medication adherence and preventive engagement.
WellFit Faith Layer
Provider Bias Training Integration
Real-time bias alerts surface when clinical patterns suggest differential treatment. Atlus logs provider interaction patterns and flags outliers for quality review — protecting patients from implicit bias in diagnosis and treatment decisions.
Guardian Agent Monitor
Language & Literacy Access
Low literacy and dialect variation are documented as Z-codes and trigger plain-language care plan generation. Audio care instructions, spoken-word follow-up reminders, and interpreter coordination are built into the WellFit delivery layer.
SmartScribe Z55.0
WellFit Community Platform
The Community Layer ACG Was Missing
ACG identifies that Dorothy is at risk. WellFit ensures Dorothy is found, connected, and supported —
through food delivery networks, faith community peer programs, BLE remote monitoring, and rural telehealth bridges.
Self-reported SDOH from WellFit feeds back into ACG analytics, creating a closed-loop data ecosystem.
24/7
Guardian monitoring
155+
Edge functions live
FHIR R4
Full compliance
👨🏾
Marcus D. Johnson
42 YRS • URBAN BLACK ADULT • MEDICAID
ACG Risk Score
79/100
ER Visits (12mo)
4
BP
162/98
PCP Relationship
None active
Insurance
Active
SDOH Burden
High
SDOH Factor Map — Urban African American Profile
Urban SDOH presents differently. Atlus recognizes neighborhood-level risk, historical system barriers, and structural inequity as clinical inputs.
Housing
Unstable, displacement risk
Z59.10 · Z59.12
System Mistrust
Prior negative care experiences
CC-MISTRUST · CC-BIAS
Employment
Unemployed, economic stress
Z56.0 · Z59.6
Social Support
Limited support network
Z60.4
ED Overutilization
No PCP, ER as primary care
Z75.1 · Z75.3
Neighborhood Safety
High-crime area, violence exposure
Z58.6 · Z65.4
Atlus Engine Pipeline — Marcus's Journey
1
ACG Flags Avoidable ED
ACG scores Marcus at 79/100 with 4 avoidable ER visits — care coordination and PCP gap identified
ACG System
2
Compass Riley + Cultural Layer
Mistrust history + provider bias flags activate. Trauma-informed care protocol. Barbershop health referral queued.
CoT Reasoning
3
SmartScribe Documents
7 Z-codes auto-generated. CCM enrollment triggered. SDOH-enriched claim submitted capturing $1,890 previously uncoded.
T+0 ICD-10
4
WellFit + Community
Peer support enrolled. Housing navigator assigned. Medication assistance secured. PCP relationship established.
WellFit Community
Urban African American Cultural Intelligence
Urban Black men face a distinct set of structural barriers. Atlus is built to recognize and address them — not just flag them.
Structural Racism as Clinical Input
Neighborhood-level redlining history, zip-code-based risk stratification, and systemic access barriers are fed into Compass Riley as context — not as excuses, but as evidence that shapes care planning and resource allocation.
Compass Riley Context
Barbershop & Community Health Networks
WellFit integrates with trusted urban community anchors — barbershops, community centers, HBCUs, and Black-owned pharmacies — as non-clinical care access points. For Marcus, trust is built where he already goes.
WellFit Community Bridge
Provider Bias Monitoring
Guardian Agent monitors clinical decision patterns for Black male patients. Pain management disparities, diagnostic delays, and dismissal patterns are logged and surfaced for quality review — protecting Marcus at every touchpoint.
Guardian Agent
Trauma-Informed Care Integration
Adverse Childhood Experiences (ACEs) and community violence exposure are documented as SDOH inputs. Compass Riley routes Marcus to trauma-informed care providers and community mental health resources without adding stigma to the clinical record.
SmartScribe Z65.4
👩🏽
Rosa Esperanza Reyes
38 YRS • RURAL HISPANIC • MEDICAID
ACG Risk Score
72/100
Prenatal Visits
2 of 14
Language
Spanish only
Documentation
Undocumented
SDOH Burden
High
Children
3 (ages 2–9)
SDOH Factor Map — Rural Hispanic, Language Barrier Priority
Language access is healthcare access. Atlus treats interpreter gaps as clinical risk factors — not administrative inconveniences.
Language Access
Spanish-only, no interpreter history
Z60.3 · Z55.8
Food Security
Farmworker household, seasonal income
Z59.4 · Z59.6
Immigration Fears
Avoids care due to status fear
CC-SAFE · Z65.8
Prenatal Access
2 of 14 visits, maternal risk
Z34.00 · Z34.90
Transportation
62 mi. to nearest OB, no car
Z59.82
Family Stress
3 children, single income household
Z63.8
Hispanic Rural Cultural Competency
Bilingual Clinical Documentation
SmartScribe generates parallel Spanish/English care plans. All WellFit patient-facing communications are delivered in Rosa's primary language — not just translated, but culturally adapted for South Texas context.
SmartScribe Bilingual
Promotora Network Integration
WellFit connects to trusted community health worker (promotora) networks in South Texas. Rosa's care coordination flows through a promotora who speaks her language and understands her community.
WellFit CHW Layer
Safe-Space Care Protocols
Immigration status never enters clinical risk algorithms or stored records beyond legal necessity. Compass Riley activates safe-space care protocols that remove barriers to engagement without exposing Rosa to institutional risk.
Compass Riley CC-SAFE
Catholic Parish Health Bridges
For many Hispanic farmworker communities, the Catholic parish is the most trusted institution. WellFit's faith-community layer includes parish health minister networks as care coordination partners for prenatal and family wellness programs.
WellFit Faith Layer