Rate of risk-standardized acute, unplanned hospital admissions among Medicare fee-for-service (FFS) beneficiaries 65 years and older with multiple chronic conditions (MCCs) who are assigned to an Accountable Care Organization (ACO).
The outcome for this measure is the number of acute unplanned hospital admissions per 100 person-years at risk for admission during the measurement period.
Denominator
1.15 Denominator
Patients included in the measure (target patient population) The target patient population for the outcome includes Medicare FFS patients aged 65 years and older with multiple chronic conditions (MCCs).
Attribution: The outcome is attributed to the ACO to which the patient is assigned. (More details are provided in the next section.)
Person-time at risk Persons are considered at risk for hospital admission if they are alive, enrolled in FFS Medicare, and not in the hospital during the measurement period. In addition to time spent in the hospital, we also exclude from at-risk time: 1) time spent in a SNF or acute rehabilitation facility; 2) the time within 10 days following discharge from a hospital, SNF, or acute rehabilitation facility; and 3) time after entering hospice care.
Exclusions
Exclusions
The measure excludes the following patients:
1. Patients without continuous enrollment in Medicare Part A or B during the measurement period.
2. Patient enrolled in hospice at any time during the year prior to the measurement year or at the start of the measurement year.
3. Patients without any visits with any of the TINs associated with the attributed ACO during the measurement year or the year prior to the measurement year.
4. Patients not at risk for hospitalization during the measurement year.
Measure Record
Most Recent Endorsement Activity
Endorsed All-Cause Admissions and Readmissions Fall Cycle 2020
Public Comments