This sample report using fake data for demonstration only

Data through · Aug 31
AM
RCS update · ADT and transition data refreshed through Aug 31
Next practice meeting · Sep 18
RCS VBC Portal

RCS VBC Performance Portal

ACO-wide performance management across utilization, cost, quality, HCC closure, and patient action.

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Analytics Portal

Executive overview, utilization, cost, quality, HCC closure, practice review, and patient action.

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Keebler

Risk, HCC opportunities, and provider-facing point-of-care workflows.

Launch Keebler →
Demo view: RCS Leadership · ACO-wide performance across utilization, cost, quality, and HCC closure.
RCS Analytics

Executive Overview

ACO-wide performance, care-model progress, and the practices that need attention.
Primary care % of total cost
5.8%
5.1% PY+0.7 pts
Admissions / 1K
284
Target 260Off track
Current census
136
-8 vs last weekWatch
Readmission rate
14.2%
Target <12%+2.2 pts
Total cost PMPM
$1,086
-3.1% YoYImproving
Timely follow-up
65.3%
Target 65%Meeting
HCC closure
68.4%
61.7% PY+6.7 pts YoY
Utilization trend
Admissions / 1K · 13 months · actual vs target
Target 260284
Direction improvingStill above target
Cost drivers
PMPM bridge · what changed YoY
Prior PMPM$1,121
Inpatient-$38
SNF-$12
Specialty+$24
Other+$9
Current PMPM$1,086
Primary care engagement signal
Management hypothesis to track over time · primary care share rising while acute utilization falls
Primary care % of total cost
5.8%
Management signal: Primary care share is +0.7 pts vs prior year while admissions /1K are down 5.6%. Use this as a directional operating signal, not a causal claim.
Quality snapshot
Current internal run-rate · compact management view
Timely follow-up
65%
AWV
67%
Readmission
14.2%
Unplanned admits
31.5
HCC closure progress
ACO-level progress only · point-of-care work stays in Keebler
2025
61.7%
2026
68.4%
1,284Open opportunities
214Seen · gap still open
Practices requiring attention
Ranked by combined utilization, cost, quality, and HCC signals · highest priority first
Rank / PracticeAdmissions /1KReadmissionCost PMPMPCP % of CostQualityHCC ClosureKey opportunityOverall
1Northside Primary Care31817.4%$1,2484.8%62%61%Increase PCP touchesNeeds attention
2Riverside Health30115.7%$1,1765.2%68%58%Hospice LOSNeeds attention
3Westview Internal Medicine28914.9%$1,0845.7%71%66%Readmission trendWatch
4Central Family Medicine27613.2%$1,1126.1%74%71%HCC closureWatch
5Lakeside Medical Group25110.8%$9727.1%81%76%Maintain trajectoryOn track
Demo view: RCS Leadership · ACO-wide access to all practices and PCPs.
Utilization

Hospital utilization at a glance

Utilization → find the gap → find the practice → find the patients
Admissions / 1K
284
Target 260Off track
Readmission rate
14.2%
Target <12%+2.2 pts
Current census
136
In facility nowWatch
Discharges · 30d
420
Transition populationReview →
Admissions trend
13 months · actual vs target glide path
240270300330 284Target 260 SepNovJanMarMayJulAug Admissions per 1,000
13-month direction: improvingActual vs target glide path
Care transition waterfall
Last 30 days · click a gap to open the patient cohort
DischargedStarting population
420
Contacted85% of discharges
356
PCP scheduled65% of discharges
274
Visited ≤7d46% of discharges
192
TOC completed42% of discharges
176
Largest opportunity: 82 contacted patients were not scheduled. Click “PCP scheduled” to review the cohort.
Practice performance
Compare utilization, transition performance, and cost across practices · click a row to filter this page
PracticeCensusAdmissions /1KReadmissionTotal Cost PMPMPart A PMPMContactedScheduled ≤7dVisit ≤7dStatus
Cost

What is driving total cost?

Connect spend to acute utilization, primary care engagement, hospice, and practice performance.
Primary care % of total cost
5.8%
5.1% PY+0.7 pts
Total Cost PMPM
$1,031
Benchmark $1,090-$59
Admissions / 1K
284
Target 260Off track
Readmission
14.2%
Target <12%+2.2 pts
Part A PMPM
$412
Prior $447-$35
Hospice spend PMPM
$118
2nd largest categoryWatch LOS
PMPM bridge · prior year to current
What moved total cost, and by how much
$1,068
Prior year
PMPM
-$42
Inpatient
-$18
SNF
+$28
Specialty
-$11
ED
+$6
Other
$1,031
Current
PMPM
Inpatient and SNF improvement are carrying the savings; specialty spend is the largest offset.
Spend by site of care
Share of total cost · current period
Inpatient38%
Specialty / Part B19%
SNF13%
ED9%
Home health9%
Other12%
PMPM vs benchmark
Trailing 8 months · lower is better
$1,000$1,050$1,100$1,150 $1,031Benchmark $1,090 JanFebMarAprMayJunJulAug Total cost PMPM
Current: $1,031 PMPMBenchmark $1,090 · lower is better
Utilization scorecard
Annualized rates vs target and prior year
MetricCurrentTargetPriorStatus
Admissions / 1K284260301Off track
Readmission14.2%12.0%15.7%Improving
ED / 1K412390438Watch
LOS4.84.55.1Watch
Primary care share of total cost
Illustrative management metric requested by RCS · monthly trend
5.8%Target 6.5%JanFebMarAprMayJunJulAug% of total cost
Prior year: 5.1%Directional care-model metric
Hospice management signal
Legacy hospice ownership makes hospice a material spend category
Hospice PMPM
$118
Second-largest spend category
Hospice LOS >180d
18
Patients for appropriateness review
Review opportunity: Riverside accounts for 6 of 18 patients with hospice LOS over 180 days.
Practice cost & utilization
See whether high spend and high utilization are concentrated in the same practices
PracticeTotal PMPMPart AAdmissions /1KReadmissionVisit ≤7dStatus
Quality

Know where quality is heading before the official result arrives

A lightweight Phase One snapshot: current internal run-rate, lagged CMS result, and year-end target.
Timely follow-up
65.3%
Target 65%Meeting
All-condition readmission
15.3
per 100 dischargesProjected 14.0
AWV completion
66.9%
Target 70%On track
Unplanned admissions
31.5
per 100 person-yrsTarget 32
Timely follow-up · early indicator vs CMS
Monthly trend · internal run-rate through Aug 2026 · CMS reported through Mar 2026
Meeting
Internal early indicatorCMS reportedPrior yearRCS target
Internal results are an earlier management signal; CMS values are shown separately because they are official but lagged.
Selected measure
Timely follow-up after acute exacerbation
Early indicator
65.3%1,528 / 2,340
CMS reported · Mar 26
60.9%Official lagged result
Projected year end
70.5%Current run-rate projection
Target
65.0%RCS operating target
Early indicator summary
Small Phase One set · internal run-rate vs official lagged result
MeasureEarly indicatorCMS · Mar 26Projected YETargetStatus
Timely follow-up after acute exacerbation65.3%60.9%70.5%65.0%Meeting
All-condition readmission15.3 /10016.1 /10014.015.0Meeting
Annual Wellness Visit66.9%48.7%81.1%70.0%On track
Unplanned admissions · MCC31.5 /100 PY33.330.932.0Meeting
HCC Closure

Track risk capture progress across the ACO

Management view only — overall closure progress and practice variation. Point-of-care HCC workflow stays in Keebler.
HCC closure rate
68.4%
PY 2025 · 61.7%+6.7 pts YoY
Open opportunities
1,284
Across 6 practicesFocus
Seen · gap still open
214
Provider visit completedNeeds follow-up
No upcoming visit
486
Open through year endView in Keebler →
Closure progress · YoY
Cumulative closure rate by month · current performance year vs prior year
Ahead of PY
2026 closure2025 closureYear-end target
40%55%70%85% 68.4%61.7%Target JanMarMayJulSepNov Closure rate (%)
2026: 68.4% closure+6.7 pts vs 2025 · target 85%
This page is for ACO-level management of closure progress. Patient-level coding prompts and provider actions remain in Keebler.
Closure by practice
Current performance year vs prior year · sorted by current closure
20262025
Oak Valley
2026
2025
79%+9 pts
Lakeside
2026
2025
76%+8 pts
Central
2026
2025
71%+7 pts
Westview
2026
2025
66%+7 pts
Northside
2026
2025
61%+7 pts
Riverside
2026
2025
58%+5 pts
Practice HCC progress
A lightweight management view — not a replacement for Keebler workflow.
Practice2026 closure2025 closureYoY changeOpen oppsSeen · still openStatus
Northside Primary Care61%54%+7 pts28658Needs attention
Lakeside Medical Group76%68%+8 pts16421On track
Central Family Medicine71%64%+7 pts20331On track
Riverside Health58%53%+5 pts30167Needs attention
Practice Review

Prepare the monthly practice conversation

Keep a consistent care-model agenda, then surface the few practice-specific issues that deserve discussion.
Primary care % of cost
4.8%Target 6.2%
Admissions / 1K
318Off track
Total Cost PMPM
$1,248Above target
HCC Closure
61%Below ACO
Timely follow-up
62%Watch
Suggested topics for this review
Fixed care-model metrics plus practice-specific outliers
3 suggested
1
Primary care engagement below trajectory4.8% of total cost vs 6.2% target · gap widened this quarter
2
Hospice length of stay above network norm6 patients >180 days · $21 PMPM above network median
3
Readmission increased this month17.4% current · +3.2 pts vs prior month · 9 repeat patients
Draft meeting agenda
Visible to the practice before the review
1. Care model scorecard
Admissions · cost · PCP share · HCC · quality15 min
2. Primary care engagement
Review trajectory and opportunities10 min
3. Hospice LOS outliers
6 patients >180 days10 min
4. Patient follow-up
9 repeat admits · 14 no timely follow-up
Patients to review
Illustrative cohorts automatically surfaced for the meeting
CohortPatientsWhy surfacedSuggested discussion
Repeat admissions9Readmission above targetReview avoidability and follow-up
Hospice LOS >180d6Practice above network normAppropriateness review
Care program eligible · not enrolled23CCM/APCM opportunityConfirm outreach / enrollment
Patient Action

Northside Primary Care

Combine performance signals to create the patient cohort that needs action.
One worklist, multiple signals. A patient can be high cost, recently discharged, overdue for follow-up, and contributing to a quality gap at the same time. Use the filters together rather than choosing one performance area.
Build a patient cohort
Combine any filters below. Metric cards provide a useful starting cohort, then refine across domains.
No additional filters applied

Patients requiring action

Use a metric card or combine filters to narrow the worklist.
PatientPCPDischargeFacilityRiskOutreachAppointmentDays leftNext action
Resources

RCS communications & practice resources

Only the essentials for Phase One.
Action required
TOC workflow refresherNorthside + Riverside · due Sep 16
Practice operations meetingSep 18 · agenda and pre-read
Recent resources
Hospital Census & TOC GuideUpdated Sep 8
Metric definitionsAdmissions, readmission, scheduling, 7-day visit
Escalation guideCritical / Serious transition workflow