Care Management Program
ACO REACH Quality Measures: Fewer Metrics, Higher Stakes
What Primary Care Teams Can Do Now to Move the Needle
ACO REACH may come with fewer metrics than other models—but the pressure to perform is higher than ever. When it comes to ACO REACH quality, the question isn’t whether your organization is tracking the required measures. It’s whether you’re truly moving the needle. Because in a program where every measure carries weight, success isn’t about checking boxes—it’s about building workflows that drive results.
As we head into NAACOS this week, it’s the perfect time to ask:
Is your ACO just reporting the numbers—or actively working to improve them?
Let’s Revisit the Four Metrics at the Heart of ACO REACH
You’re likely already familiar with them, but here’s what CMS is asking of your organization:
- Unplanned Admissions for Multiple Chronic Conditions (UAMCC)
- Timely Follow-Up After Acute Exacerbation of Chronic Conditions (TFU)
- All-Cause 30-Day Readmissions (ACR)
- CAHPS® Patient Experience Survey
Three are claims-based. One is survey-based. But all of them require the right processes, tools, and insights to influence in a meaningful way.
So, What Can You Actually Do About Them?
These measures are tight. They’re targeted. But they’re also entirely actionable—if you have the right infrastructure in place. At AaNeel, we work with ACOs that aren’t just measuring—they’re moving. Here’s how.
1. Unplanned Admissions (UAMCC)
Chronic patients aren’t going to stop needing care. But how often that care leads to the hospital? That’s up to you. What should you focus on?
- Early engagement with rising-risk patients
- High-touch chronic care management
- Remote monitoring and behavioral health flags
💡 AaNeel in Action: We helped one ACO build a risk dashboard that surfaced patients with diabetes and CHF flagged by utilization trends—not just diagnoses. Proactive outreach cut ED admissions in half over two quarters.
2.Timely Follow-Up (TFU)
Time matters. The longer the delay after an acute event, the more likely the patient is to destabilize. Where should you focus?
- ADT alerts that trigger scheduling and outreach
- Care team workflows that prioritize speed
- Closing the loop—no patient falls through the cracks
💡 AaNeel in Action: One client saw a 32% jump in follow-up completion by using our platform’s ADT alerts and auto-assigned follow-up tasks to the care coordination team within 24 hours of discharge.
3. 30-Day Readmissions (ACR)
Readmissions aren’t random. They’re a reflection of what didn’t happen between the discharge and the follow-up. What should you focus on?
- Med reconciliation within 48 hours
- Social determinant screening and connection to services
- Reassessment at 3, 7, and 14 days post-discharge
💡 AaNeel in Action: We supported an ACO that built a “post-discharge bundle” right into their EMR workflow—care plan review, telehealth touchpoints, med rec, and navigator check-ins. Readmissions dropped. Quality scores climbed.
4. CAHPS® Survey
Patient experience is no longer a soft metric. It’s reportable—and it’s tied to reimbursement. Where should your focus be?
- Real-time patient feedback
- Consistent, personalized engagement
- Training your care team on communication, not just compliance
💡 AaNeel in Action: A client organization used AaNeel to flag patient sentiment trends based on CAHPS themes. They adjusted workflows to proactively address common complaints—confusion at discharge, follow-up clarity, and communication gaps. Their satisfaction scores improved by nearly 20%.
This Isn’t Just About Compliance. It’s About Control.
Yes, CMS is scoring you. But the goal isn’t just to report—it’s to influence.
To improve. To control outcomes.
And that’s only possible when your platform gives you:
- Real-time insights that connect to workflows
- Predictive risk modeling that informs outreach
- Embedded care pathways that guide the team from alert to action
- Dashboards that show impact, not just activity
That’s what AaNeel delivers. Not just a window into your performance—but a way to shape it.
Ready to Make Quality Measures Work for You?
Let’s turn these four metrics into four big wins for your ACO.
📅Request a Demo with AaNeel Today
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