Accountable Care Organization

This is an ACO-level measure of days at home or in community settings (that is, not in acute care such as inpatient hospital or emergent care settings or post-acute skilled nursing) among adult Medicare Fee-for-Service (FFS) beneficiaries with complex, chronic conditions who are attributed to ACOs participating in the ACO REACH model. The measure includes risk adjustment for differences in patient mix across ACOs, with an additional adjustment based on patients’ risk of death.

This is a measure of follow-up clinical visits for patients with chronic conditions who have experienced an acute exacerbation of one of six conditions (eight categories) of interest (coronary artery disease [CAD] {high or low acuity}, hypertension {high or medium acuity}, heart failure [HF], diabetes, asthma, and chronic obstructive pulmonary disease [COPD]) and are among adult Medicare Fee-for-Service (FFS) beneficiaries who are attributed to entities participating in the CMMI Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH) model.