Off the Shelf TA

Readmission Predictor using Artificial Intelligence/Machine Learning

Hexplora is an Analytics and Data Management company that delivers the Readmission Predictor in a cloud-first model using a state-of-the-art Artificial Intelligence/Machine Learning platform on Microsoft Azure.

Having the right insight at the right time is critical for the time-sensitive task of reducing readmissions within 30 days. Improvements in this health outcome can positively impact several Community Partner (CP) and ACO shared pay for performance quality measures including: Community Tenure, Hospital Readmissions, and even Emergency Department Visits for Adults with Mental Illness, Addiction or Co-occurring Conditions. Hexplora helps you provide this insight to Care Coordinators and ACO Care Managers as soon as any patient is discharged from an inpatient event. Hexplora integrates multiple enrollee data sets including EHR demographic information, medical history using MassHealth claims, health related social needs (HRSN) variables from MassHealth’s enrollment data, care gaps calculated using Hexplora’s HEDIS engine (Hexplora is a NCQA certified company), predictive risk scores, and comorbidities using the HCC model. Simultaneously using all these data sets, an Artificial Intelligence/Machine Learning algorithm is used by Hexplora’s data scientists to predict enrollee readmission probability at the point of inpatient discharge. Not only does the Readmission Predictor accurately quantify readmission probability, but it also provides population-based and individual enrollee-detail health factors that impact readmission probability. The enrollee detail level data allows the CP and the ACO to consider case-by-case interventions. The population-based insights allow the CP and the ACO to consider larger scale health system changes to address readmission factors.

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ACOs and CPs would be able to customize the reporting based on what health factors they like to see on the reports




$25,000 - $75,000


Ongoing Availability


Solution blueprint in 2 weeks after data is shared, solution delivery in 4 weeks and customizations and support for 8 weeks


Either single or multiple participants (one ACO or CP per TA project OR multiple ACOs or CPs per TA Project)


Population Health Management