Why and how are patient's flagged for ACP conversations?

We will use the logic below to drive a series of labels in the patient chart.

1. MSSP patients
2. Serious Illness patients
3. ACP ASAP (High-impact ACP patients = MSSP ACO + Serious Illness + No recent ACP. This is the same logic we use to flag patients in need of a serious illness conversation the Huddle and ACP Tool)