The ACO REACH Model: Health IT to Support Success

By Diana Bauza, Content Writer for Audacious Inquiry
Twitter: @A_INQ

In February 2022 the Centers for Medicare and Medicaid Innovation (CMS Innovation Center) introduced the ACO REACH Model to promote greater health equity among the beneficiaries receiving care through accountable care organizations (ACOs). In this article, we define the ACO REACH Model, cover what the model is changing for ACOs, and demonstrate how access to quality data and improved care coordination will play a big role in driving success when the first performance year begins in January 2023.

What is ACO REACH?

The Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model is a pilot program designed to replace the current Global and Professional Direct Contracting (GPDC) Model. CMS and the Centers for Medicare and Medication Innovation (CMMI) developed ACO REACH as part of an effort to advance health equity goals set by the Biden-Harris Administration. The ACO REACH Model will help the Centers for Medicare and Medicaid (CMS) test a program that will address health inequities and offer better support for provider-led organizations in risk-based arrangements.

Both new participants and those transitioning from the GPDC Model will need to develop a strategy that
allows them to remain compliant with ACO REACH requirements while maximizing revenue and shared savings while managing total cost of care through care management strategies To do so, it will be necessary to address health disparities beneficiaries face and support better health outcomes to reduce avoidable utilization, improve quality scores, and ensure safe care transitions.

What Makes the ACO REACH Model Different?

The ACO REACH pilot will allow CMS to test a model that can impart changes or adjustments to the MSSP and focuses on incorporating measures to track participants’ adherence to health equity goals. There are three principal health equity components in the ACO REACH Model that do not exist in the GPDC Model:

  1. Health Equity Plan – REACH ACOs must establish a Health Equity Plan that they will implement in 2023 to identify health disparities, reach out to underserved patient populations, and develop a strategy to reduce the barriers to equitable care that they face. To help REACH ACOs begin developing their health equity plan, The CMS Innovation Center shared this Disparities Impact Statement Tool.
  2. Health Equity Benchmark Adjustment – The ACO REACH Model aims to improve the GPDC Model risk approach by creating beneficiary-level risk adjustments for REACH ACOs that treat a higher percentage of underserved populations that may have more complex healthcare needs.
  3. Health Equity Data Collection – REACH ACOs must collect beneficiary-reported demographic and social determinants of health (SDOH) information that covers data elements required by the United States Core Data for Interoperability Version 2: race, ethnicity, language, gender identity, and sexual orientation.

To view a comprehensive comparison between the ACO REACH Model and the GPDC Model, CMS Innovation Center created a table that you can view here.

How Data Quality Factors into ACO REACH?

With the strong focus on health equity of the ACO REACH Model, data quality will become even more important. REACH ACOs will need to have health information technology solutions that allow them to identify underserved patients in their beneficiary population through the standardized collection of health equity data.

Dr. Dora Hughes, Chief Medical Officer at CMMI, noted that the ACO REACH Model will require participants to know the demographics of their populations, and include information about the data sources and data itself, while also clearly identifying how they will use the data to address any disparities found. Any successful health equity plan must be built using accurate, complete, and standardized data.

Any successful health equity plan must be built using accurate, complete, and standardized data. With standards and data exchanges in place, health information technology supports a data-driven four-step approach to promoting health equity. These four steps are key to an ACO’s success to better understand health disparities and inequities in their populations:

  1. Identify – Use demographic and similar data elements to understand population composition, especially as it relates to those who have been historically underserved, marginalized, and adversely affected by persistent poverty and inequality.
  2. Exchange – Share those data elements with others involved in the patient’s care.
  3. Analyze – Conduct simple and statistical analyses, alongside clinical data, to identify disparities among populations.
  4. Intervene – Use the analysis to develop, execute, and evaluate interventions designed to promote health equity.

Ensuring that providers and care team members can access demographic, SDOH and health equity data for their patients is also crucial to successfully identifying and addressing disparities. Without it, identifying the beneficiaries with high-priority or unmet healthcare needs can be burdensome, time-consuming, or fraught with errors, making efforts to provide outreach and engagement for improved health outcomes ineffective.

Improving Patient Outcomes and Quality Measures

Another key to success for ACO REACH participants in the performance period is to focus on improving patient outcomes and quality scores. One approach to accomplish these goals is through monitoring high-risk patients and engaging them proactively for preventive care to reduce avoidable utilization and readmissions. Preventing frequent emergency department visits and rehospitalizations not only reduces costs, but improves patient health, satisfaction with care they receive, and can help boost quality measures that impact revenue.

Quality measures REACH ACOs may be focused on include:

  • Risk-standardized, all-condition readmissions
  • All-cause, unplanned admissions for patients with multiple chronic conditions
  • Days at home for patients with complex, chronic patients
  • Timely follow-up after acute exacerbations of chronic conditions
  • Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey

Once ACOs have leveraged health IT to identify high-acuity and underserved patients, they can set up tracking with their health information exchange (HIE) and electronic health record (EHR) system to stay updated on health encounters those patients have in real time. Setting up data feeds for admission, discharge, transfer (ADT) alerts directly in provider workflows makes it easier for care teams to keep track of their patients and provide outreach when it matters—not days or weeks later. Providers and care managers can also target their efforts to reach out to the patients who need more support and resources to achieve better health outcomes by providing the right care at the right time.

Why REACH ACOs Need Strong Care Coordination Solutions

The keystone to success in the ACO REACH Model is to reduce total cost of care by ensuring safe care transitions through effective care coordination. REACH ACOs will need to ensure they have health IT solutions in place that facilitate collaboration among care team members during transitions of care to support better outcomes. For example, implementing an encounter notification system with customized, actionable clinical data feeds that notify care teams when their patients are hospitalized, transferred, or discharged can ensure that providers know what is happening with their patients in real time to prevent gaps in care.

In addition to real-time encounter alerts, it is important for providers to have access to clinical documents for their patients, especially post-discharge when the opportunity to prevent a readmission and support patient health outcomes is most critical. Setting up an automated discharge document retrieval system can play a pivotal role in enhancing care coordination efforts because care team members can reinvest time that may have been spent chart chasing to actually engage with and treat patients in their care.


Health IT solutions can allow ACO REACH participants to provide proactive outreach to reduce avoidable utilization and hospital readmissions with the ultimate aim of improving patient health and ensuring more equitable care for beneficiaries. REACH ACOs can set themselves up for success in the upcoming performance period by ensuring they have the technology and tools necessary for providers to access actionable, real-time insights about their patient populations as they move throughout the care continuum to improve health equity, enhance care coordination and achieve better patient outcomes.

This article was originally published on the Audacious Inquiry blog and is republished here with permission.