Before January: A Quick ACO Readiness Check for the 2025 Reporting Period
December may feel like the end of the year, but for ACOs, it is the final checkpoint before a new performance cycle begins. In 2025, APP Plus became the required reporting framework, raising the bar for how ACOs manage data, measures, and workflows across all participating practices. As you head into 2026, a few targeted checks can confirm that your team is aligned and ready for the next cycle. This post walks you through those steps in a straightforward, direct way.
Understand the APP Plus Structure for 2025
Before you make any final decisions, you should be clear on what APP Plus actually includes for the 2025 performance year. Many ACO teams have heard numbers like “Eleven measures” floating around. That is the long-term trajectory, not the current requirement.
For 2025, APP Plus includes six measures.
Four eCQMs or Medicare CQMs
These focus on chronic and preventive care. You will report:
1. Diabetes: Hemoglobin A1c Poor Control
2. Controlling High Blood Pressure
3. Breast Cancer Screening
4. Depression Screening and Follow-Up PlanOne CAHPS survey measure
This reflects patient experience, communication, and access.One administrative claims measure
This will be auto-calculated by CMS.
This streamlined set is intentional. CMS is building a future reporting foundation that supports population health and chronic care management across all ACOs. You may see the measure set expand to eleven measures in the future, but for 2025, your job is to master these six.
Tip:
If you are unsure which eCQM or Medicare CQM versions your practices support, pause now and verify. The version mismatch problem is one of the most common compliance errors among ACOs.
2. Confirm Your Collection Type Across the Entire ACO
APP Plus requires complete alignment, meaning your ACO must use one collection type across all practices and for all patients. You can choose from:
eCQMs
MIPS CQMs
Medicare CQMs
This decision affects your workflows for the entire year.
Why this matters
If half your practices plan to submit eCQMs and the other half plan to submit MIPS CQMs, your ACO will run into issues during data aggregation, validation, or submission. The rule is simple. An ACO cannot mix collection types.
Action Step:
Create a short list of your ACO’s participating TINs and confirm the selected collection type for each one. If you notice a variation, resolve it before the new performance year begins.
Question you might ask:
What if a provider’s EHR cannot produce the collection type the ACO chooses?
In most cases, that provider will need to work with the ACO to update their reporting functionality or use a certified vendor. Waiting until January will only shrink your options.
3. Validate Your 12-Month Data Plan
APP Plus requires 12 months of continuous data for every patient and every participating practice, including all payers, not just Medicare.
Key elements to confirm:
Your ACO’s data-sharing agreements are current.
All sites can produce the same measure logic.
Patient attribution and denominator requirements are consistent across TINs.
Each practice understands the full-year reporting expectation.
Why this can be challenging
Some practices only begin capturing quality measure fields in the spring or summer. If a key data field, such as depression screening documentation, was inconsistent during the first half of the year, it affects your entire measure score.
Tip:
Set up your January data validation timeline now. When the first reports come in, you want to catch gaps early.
4. Test Your Data Aggregation Model Now
If you have more than one EHR system across your ACO, data aggregation is not a nice-to-have. It is a requirement.
Your fact-finding mission:
Identify who owns the raw quality data for each practice.
Confirm whether the measure calculation happens inside the EHR or through your registry.
Validate your mapping file for each measure.
Run a test export with simulated January data.
Why this matters
The biggest risk ACOs face is inconsistent mappings. For example, one EHR might use a structured field for depression screening, while another might log it in a free-text note. When that data flows into a central registry or warehouse, the measure numerator collapses.
Action Step:
Ask each practice to send a sample file for each of the four clinical measures. Review whether the fields align with your measure logic. Look for missing values, mismatched codes, and inconsistent documentation patterns.
5. Review Workflows for Diabetes, Hypertension, Breast Cancer Screening, and Depression Screening
Because the APP Plus measures focus so heavily on chronic and preventive care, your ACO should treat each one as a workflow project, not just a reporting task.
Diabetes (A1c Control)
Confirm that each practice has a uniform process for capturing A1c values.
Make sure the A1c order is tied to a structured field.
Train staff to schedule follow-up before the patient leaves the visit.
Hypertension (BP Control)
Check that every site uses the same blood pressure measurement protocol.
Encourage second readings for high initial readings.
Standardize how home blood pressure monitoring is logged.
Breast Cancer Screening
Review your recall lists for overdue patients.
Confirm that screening records from outside facilities can be imported or documented in a structured field.
Depression Screening and Follow-Up Plan
Validate that PHQ-2 and PHQ-9 scores are stored consistently.
Check that positive screens trigger a follow-up plan that counts for measure credit.
Tip:
Assign one person per practice to verify compliance for all four clinical measures by the second week of January.
6. Align Your ACO’s POP Health Activities With APP Plus Measures
Even though APP Plus focuses on six measures in 2025, the larger direction CMS is taking is clear. The goal is better chronic care, fewer preventable hospitalizations, and stronger coordination across all participating practices.
How you benefit by aligning early:
You reduce your administrative workload.
You avoid year-end surprises.
You set your team up for the upcoming expansion of APP Plus in future years.
You gain control over the care gaps that matter most for cost and quality.
Action Step:
Map your current care gap outreach workflows to each APP Plus measure. If your ACO already runs diabetes or hypertension outreach campaigns, integrate follow-up scheduling, depression screening reminders, or breast cancer screening outreach into the same process.
7. Schedule Your January Quality Kickoff Now
January will move quickly. Once the performance year begins, you want to be ahead of every reporting and operational task. A structured kickoff meeting gives your ACO a clear plan and reduces confusion across practices.
Your kickoff agenda should include:
Review of APP Plus measure definitions
Explanation of the ACO’s chosen collection type
Overview of data aggregation steps and reporting timelines
A walkthrough of care gap outreach procedures
Assignments of measure owners for each practice
Confirmation of monthly reporting deadlines
Tip:
Send the kickoff agenda this month so no one is surprised by what is expected in January.
You may feel the weight of APP Plus as you wrap up 2025, but you still have time to set up a clear, steady start for the new year. When you understand the measure set, align your collection type, validate your data, and strengthen chronic care workflows, you create a reporting system that supports both quality and consistency. These steps help your ACO enter 2026 with fewer questions and more control.
A thoughtful plan today can prevent avoidable problems later and keep your ACO ready for the next phase of quality reporting.
If you want support verifying your APP Plus measure mappings, data feeds, or workflows, Chirpy Bird can walk you through a tailored readiness check for your ACO.
Book a 30-minute session with our ACO specialists today and enter 2026 with confidence.
