Hit risk-adjusted 30-day all-cause readmission ratio ≤ 0.90 across HRRP cohorts in two quarters via Project RED, 72-hour follow-up, and billed TCM that funds the transitions team.
Hit risk-adjusted 30-day all-cause readmission ratio ≤ 0.90 across HRRP cohorts in two quarters via Project RED, 72-hour follow-up, and billed TCM that funds the transitions team.
Risk Score Completion (24h) from 45 to 100 (weekly). High-Risk Patients Receiving Full Bundle from — to ≥ 90 (weekly). Project RED Bundle Compliance from 55 to ≥ 90 (weekly).
16 weeks.
Integrates with EHR with discharge module (Epic Discharge Navigator / Cerner Discharge), Risk-stratification model (LACE / HOSPITAL score / vendor model), ADT feed to PCP / ACO partners (CommonWell / Carequality), Outpatient pharmacy + meds-to-beds program through the AEROSS Execution Mesh. All writes are credit-metered, CAPS-gated, and audit-stamped.
CMS Hospital Readmissions Reduction Program (HRRP) — FY 2024 cohorts: AMI, HF, PN, COPD, CABG, THA/TKA; CMS Transitional Care Management codes 99495 / 99496; Conditions of Participation §482.43 — discharge planning standards; OIG guidance — TCM billing requires interactive contact within 2 business days All agent actions inherit AEROSS CAPS governance — autonomy ceilings, human approval gates, and a tamper-evident audit log.