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ACO-Level Administrative Claims-Based Measure of Days at Home for Patients With Complex Chronic Conditions

Bibliographic Data

ID9097285
AuthorsKyle Bagshaw (0009-0008-7514-9519, Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (YNHHSC/CORE), New Haven, CT, corresponding author), Yongfei Wang (0009-0000-3231-0749, Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (YNHHSC/CORE), New Haven, CT, corresponding author), Zhenqiu Lin (0000-0002-3089-141X, Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (YNHHSC/CORE), New Haven, CT, corresponding author), Judith Herrin (0000-0002-3671-3622, Yale University), Jeph Herrin (Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT), Aruna Jhasti (Center for Medicare and Medicaid Innovation), Kelly A Kyanko (0000-0001-6816-2207, New York University), Kelly Kyanko (NYU Grossman School of Medicine)
Year2026
Volume64
Issue3
Pages101-109
Publication date2026-03-01
Peer ReviewedYes
Open AccessNo
TypeARTICLE
VenueMedical Care (JOURNAL)
Journal identifiersISSN: 0025-7079 • E-ISSN: 1537-1948
PublisherOvid Technologies (Wolters Kluwer Health) (PUBLISHER)
DOI10.1097/mlr.0000000000002255
PMID41295947
OpenAlexW4416711366
LanguageEN
Citations received1
References cited24

BACKGROUND: Stakeholders have called for measures of how much time patients spend at home and in the community to incentivize coordinated, timely, and primary care-based services and reduce unnecessary acute care. OBJECTIVES: We developed a claims-based "Days at Home" Accountable Care Organization (ACO) measure for Medicare beneficiaries, intended to assess the number of days in a calendar year that adults with complex chronic disease spend at outside acute or postacute inpatient facilities. METHODS: Testing used 2017 and 2018 Medicare claims for fee-for-service patients enrolled in 610 Shared Savings Program ACOs. We used a split-half method for reliability testing, and a survey of technical experts and comparison to related measures for validity. The measure adjusts for 51 clinical and demographic variables and one social determinant of health (Medicaid dual-eligibility). To avoid unintended consequences of discouraging medically appropriate care and excessive reliance on nursing homes, the measure adjusts for mortality and new admissions to long-term nursing home care. RESULTS: The cohort (N=1,154,779) was predominantly White (84.9%) and aged 65 years or older (84.0%), and 22.8% were Medicaid dual-eligible. Mean ACO-level adjusted days at home was 330.4, ranging from 291.0 to 345.9 days (interquartile range: 329.1-332.1). Split-sample reliability was 0.833. External experts rated the measure as having face validity; in assessing external validity the measure generally correlated with related measures. CONCLUSIONS: The Days at Home ACO measure is a reliable and valid measure that can be used to promote coordinated and prevention-focused home-based and community-based care

Chronic disease · Health services research · Measure (data warehouse) · MEDLINE · Chronic Disease Management Strategies · Frailty in Older Adults · Geriatric Care and Nursing Homes

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Unique citing works1
Citations per year1
Citation span2026 - 2026 (1)
Citation velocitycurrent
Highly citedNo
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