APP Plus Measure Deep Dive #7: Hospital Readmissions
When a patient leaves the hospital, that’s supposed to be the end of one chapter, not the start of another. Yet, for many practices participating in ACOs, the story often continues sooner than expected—with a readmission. Under the APP Plus framework, Hospital Readmissions (Measure #7) plays a critical role in determining performance scores, shared savings, and overall care quality.
This measure captures the rate of unplanned hospital readmissions within 30 days of discharge, focusing on transitions of care that don’t go as planned. While it’s a claims-based, risk-adjusted measure, practices still have meaningful influence over the data behind it. In this deep dive, we’ll explore how this measure works, how ACOs and clinicians can improve performance, and why understanding readmissions can transform both patient outcomes and reimbursement.
1. Understanding the APP Plus Hospital Readmissions Measure
The Hospital Readmissions measure under APP Plus originates from CMS’s Hospital-Wide, All-Cause, Unplanned Readmission Measure (HWR, CMS1135/CMS009). It assesses the number of unplanned inpatient readmissions within 30 days of a hospital discharge for patients 18 years or older.
The intent is simple: evaluate how well providers manage care transitions and post-discharge follow-up to prevent unnecessary hospitalizations. However, the calculation is anything but simple.
CMS determines this rate using Medicare Fee-for-Service (FFS) claims data rather than provider-submitted data. It’s a risk-adjusted measure, meaning patient factors—like age, comorbidities, and recent hospitalizations—are considered to ensure fairness. Still, ACOs and providers can influence performance by strengthening processes around discharge planning, communication, and coordination.
Why This Measure Matters
It directly impacts your APP Plus Quality Performance Score.
High readmission rates can offset shared savings gains.
Reducing readmissions signals strong population health management and better patient experience.
2. How CMS Calculates Readmission Rates: What You Can and Can’t Control
The Hospital Readmissions measure is calculated from claims submitted to CMS, not data you manually report. Here’s the process:
Patient Discharge Occurs: CMS identifies discharges from inpatient claims.
30-Day Window Begins: CMS tracks whether that patient returns to any hospital within 30 days.
Risk Adjustment Applied: Statistical models adjust for expected readmission risk based on patient and clinical factors.
Final Rate Reported: CMS reports a standardized rate reflecting observed versus expected readmissions.
So, if you can’t submit this measure manually, where’s your control? It lies in the upstream processes, your care coordination, discharge workflows, and documentation.
Your ACO’s readmission performance depends on how effectively your team ensures patients transition safely back into the community, understand their medication plans, and receive follow-up care.
3. Optimization Strategies for ACOs: Reducing Readmissions the Right Way
Even though this measure is claims-based, ACO leaders and practice managers have several levers to pull. Here are five actionable strategies to strengthen performance and ensure CMS data works in your favor.
1. Build a Transitional Care Coordination System
Establish a structured process for post-discharge follow-up. Schedule phone calls or nurse visits within 48 hours of discharge. Confirm medication adherence, appointment scheduling, and red flag symptoms.
Tip: Use your EHR to flag recent discharges automatically and assign tasks to care coordinators.
2. Identify High-Risk Patients Before Discharge
Work with hospital partners to identify patients most likely to be readmitted—those with multiple chronic conditions, poor social support, or limited health literacy. Use predictive analytics tools within Epic or your population health platform to trigger alerts.
Insider note: Many ACOs overlook integrating social determinants of health (SDOH) data, yet it’s one of the strongest predictors of readmission.
3. Align Primary Care and Post-Acute Care
Collaborate with skilled nursing facilities (SNFs), home health agencies, and rehabilitation centers to streamline transitions. Share discharge summaries and care plans electronically, ideally through your EHR or a secure HIE connection.
Tip: Track which facilities have the highest readmission rates for your patients and engage them in a quality improvement dialogue.
4. Audit Claims and Internal Data Regularly
Although you don’t submit data for this measure, internal audits help ensure your documentation aligns with what CMS sees in claims. Inconsistencies between your EHR data and claims can flag attribution or quality issues.
Tip: Review discharge codes and diagnosis accuracy to ensure claims data truly reflect patient outcomes.
5. Develop a Readmission Review Committee
Create a multidisciplinary team to review each readmission. Ask:
Was this readmission preventable?
Were discharge instructions clear?
Did the patient have access to transportation and follow-up appointments?
These insights can guide practice-level interventions and continuous improvement.
4. Clinical Insights for Providers
While ACO administrators manage the data, clinicians manage the reality behind it. Reducing readmissions begins with strong clinical practices and communication.
1. Strengthen Discharge Planning
Start discharge planning at admission. Ensure patients understand medication changes, follow-up instructions, and warning signs that require immediate attention. Provide written materials in plain language and confirm understanding through teach-back.
Tip: For Epic users, leverage the “Discharge Navigator” and “MyChart Care Companion” to send reminders and educational materials directly to patients.
2. Emphasize Transitional Care Management (TCM) Visits
Schedule TCM visits within 7 to 14 days post-discharge. Use these appointments to reconcile medications, review discharge instructions, and address new symptoms early.
Insider note: Many ACOs see measurable readmission reductions when they tie nurse-led outreach to physician follow-up scheduling.
3. Enhance Care Team Communication
Hospitalists, primary care physicians, and specialists must communicate seamlessly. Implement shared communication logs or EHR alerts for recent discharges.
Tip: Encourage documentation of key information like discharge reason, hospital course summary, and follow-up plan—these details reduce duplication and confusion.
4. Leverage Telehealth for Post-Discharge Monitoring
For patients with mobility issues or chronic conditions, telehealth check-ins within the first week after discharge can prevent minor complications from escalating.
5. The Role of Risk Adjustment: Why Understanding It Matters
Risk adjustment accounts for patient complexity, ensuring practices aren’t penalized for serving higher-risk populations. However, it’s not a “set it and forget it” feature. CMS uses multiple variables from claims—diagnoses, prior utilization, and demographics—to predict expected readmissions.
Action Tip for ACOs:
Ensure your clinical documentation accurately reflects all patient conditions. Omissions in diagnoses can make your population appear “healthier” on paper, reducing your risk adjustment factor and inflating your readmission rate unfairly.
Example: A patient with diabetes, COPD, and heart failure has a higher expected risk than a single-condition patient. If any of these conditions are undocumented, your ACO’s readmission rate could appear worse than it truly is.
6. Data Integrity and Workflow Alignment
Even though the readmission measure relies on CMS data, practices must ensure that EHR data integrity supports quality analytics.
Verify discharge data accuracy. Incorrect discharge status codes can skew results.
Align internal reporting dashboards. Build custom reports to flag recent discharges and track follow-up visits within 30 days.
Engage analytics teams. Your ACO’s data analysts can correlate internal metrics to CMS benchmarks to predict performance before official results are released.
Insider note: Practices that proactively reconcile internal EHR discharge data with payer claims see fewer surprises during CMS performance feedback.
7. Common Pitfalls to Avoid
Treating readmission reduction as a hospital problem only.
ACOs that silo readmission management fail to address primary care follow-up gaps.Ignoring patient feedback.
Patient-reported barriers (transportation, medication confusion, or unclear instructions) often highlight preventable causes.Neglecting real-time data monitoring.
Waiting for quarterly reports to identify trends means missed opportunities for timely intervention.
Hospital readmissions tell a story; one about how well we manage the moments after discharge, not just the moments inside the hospital. For ACOs reporting under APP Plus, this measure is more than a number. It’s a reflection of your care coordination, documentation discipline, and patient engagement.
Reducing readmissions requires a team effort across administrators, clinicians, and care coordinators. When you focus on the upstream factors, timely communication, risk awareness, and patient empowerment, you not only improve your measure score, but you also build trust and better health outcomes for your patients.
If your ACO needs help analyzing readmission trends or optimizing APP Plus performance, contact Chirpy Bird. Our team can help you strengthen your readmission strategies and stay ahead of CMS benchmarks.
