Continuous variable, e.g., average

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 composite measure assesses the percentage of hospitalizations for adults aged 18 years and older at the start of the inpatient encounter during the measurement period with a length of stay equal to or greater than 24 hours who received optimal malnutrition care during the current inpatient hospitalization where care performed was appropriate to the patient's level of malnutrition risk and severity.

This measure evaluates the extent primary care physicians (PCPs) provide care-based and procedural-based services core to primary care. For each PCP, the resulting value reflects an average of the weighted proportion of services within each category provided during the measurement period.