Introduction

Aviator Health is building an AI‑native, human‑led care navigation layer for Medicare and Medicare Advantage beneficiaries living with chronic and serious conditions. This page explains what we measure, how we measure it, and which external benchmarks inform our goals. To protect privacy, we publish only de‑identified, aggregate metrics consistent with HIPAA and our Notice of Privacy Practices.

Beginning with the baseline period October–December 2025 (Q4 2025), we will post quarterly KPI updates starting in Q1 2026. Where relevant, our methods align with the Centers for Medicare & Medicaid Services (CMS) Principal Illness Navigation (PIN) policy effective January 1, 2024. See the American Academy of Family Physicians overview of PIN codes G0023, G0024, G0140, and G0146 and service requirements, including initiating visit, documentation, and auxiliary personnel standards (AAFP; Rural Health Info).

Outcome snapshots (baseline and targets)

We will publish the first KPI results for Q4 2025 by April 30, 2026. To increase transparency, we are pre‑registering our initial targets informed by external evidence and policy.

KPI	Baseline (Q4 2025)	2026 target	Rationale/benchmarks
30‑day all‑cause readmission rate	To be published 4/30/26	≥10% relative reduction vs. baseline by Q4 2026	Evidence that navigation reduces acute utilization; oncology programs report 15–20% acute care reductions (Thyme Care). PIN enables structured monthly navigation under CMS (AAFP).
30‑day ED return rate (post‑index ED visit)	To be published 4/30/26	≥12% relative reduction vs. baseline by Q4 2026	Navigation interventions reduce ED use; NavSTAR showed fewer ED visits vs. usual care (NavSTAR).
DME order‑to‑delivery cycle time (days)	To be published 4/30/26	Median ≤21 days by Q4 2026	Faster mobility access is core to our program operations; aligns with our mobility workflow focus.

Notes

• Targets are organization‑level goals; payer or cohort‑specific goals may differ. We will report medians/IQR and confidence intervals where applicable.

• Any target revisions will be documented in the changelog on this page.

What we measure (domains and KPIs)

We organize measurement into six domains. Representative KPIs are listed below; final reported KPIs may expand as data quality matures.

• Access and timeliness

• Median time from referral to navigator onboarding (days)

• Time to first specialty appointment (days) for new diagnosis

• 7‑day post‑discharge follow‑up completion (%)

• Care coordination quality

• Medication reconciliation completed within 72 hours post‑discharge (%)

• Closed‑loop referral completion within 30 days (%)

• Prior authorization cycle time (days)

• Utilization and safety

• 30‑day ED return rate following index ED visit (%)

• 30‑day all‑cause readmission rate (%)

• Avoided ED visits per 1,000 members (difference‑in‑differences vs. matched controls)

• Social needs resolution (SDOH)

• Documented SDOH need addressed within 14 days (%)

• Successful SNAP or home‑delivered meals enrollment (count per 1,000)

• Experience and equity

• Net Promoter Score (NPS) or top‑box satisfaction (% “very satisfied”)

• Disparity gap (e.g., follow‑up completion) by language and rurality (percentage‑point difference)

• Economic impact

• Total medical cost delta PMPM vs. matched controls ($)

• DME order‑to‑delivery cycle time (days)

KPI dictionary and current reporting status

KPI	Definition and formula	Primary data sources	Unit	Cadence	Q4 2025 status
7‑day post‑discharge follow‑up	Numerator: members with an outpatient/telehealth follow‑up within 7 days after inpatient/ED discharge; Denominator: eligible discharges; Exclusions: hospice, death within 7 days	Health system ADT feeds; claims; navigator logs	%	Quarterly	Baseline in collection
30‑day ED return rate	Index ED visits followed by any ED visit within 30 days ÷ eligible index ED visits	Claims; HIE; hospital data	%	Quarterly	Baseline in collection
DME cycle time	Calendar days from clinician order signed to member receipt of device (wheelchair, rollator, scooter)	Navigator workflow system; supplier confirmations	Days	Quarterly	Baseline in collection
Closed‑loop referral completion	Referrals with documented appointment kept within 30 days ÷ total referrals placed	EHR referral data; navigator confirmations	%	Quarterly	Baseline in collection
SDOH need resolved ≤14 days	Members with at least one documented SDOH need (food, transport, housing) resolved within 14 days ÷ members with new SDOH need	Navigator assessments; community partner confirmations	%	Quarterly	Baseline in collection

Notes:

• All reported results are de‑identified and aggregated; small‑cell suppression rules apply when n<11.

• Where feasible, we will present stratum‑specific results (age bands, dual‑eligibility, language) and confidence intervals.

Methods overview

• Study design and attribution

• Primary approach: pre/post within‑member analysis complemented by matched control cohorts using propensity scores (age, sex, risk score, condition set, baseline utilization) when appropriate.

• Sensitivity analyses: inverse probability of treatment weighting (IPTW) and falsification endpoints (e.g., unrelated imaging use) to probe bias.

• Populations

• Inclusion: Traditional Medicare or Medicare Advantage adults (≥18) enrolled in Aviator navigation via a documented initiating visit per CMS PIN; condition cohorts include COPD, CHF, dementia, Parkinson’s disease, stroke recovery, chronic pain, MS, and new serious diagnoses.

• Exclusion: Hospice at index, incomplete coverage, or insufficient lookback for baseline risk.

• Outcomes and measurement windows

• Access and coordination: 0–30 days post‑enrollment or post‑discharge.

• Utilization and cost: 0–30 and 0–90 days; annualized rates when applicable.

• Data sources and governance

• Claims (payer partners), ADT and EHR data (provider partners), navigator workflow data, community‑based organization confirmations. Data use complies with BAAs and HIPAA; de‑identification per §164.514(b).

• Risk adjustment and case‑mix

• HCC/age/sex risk models; social risk covariates when available (e.g., dual‑status, ADI). Results additionally stratified to reveal equity gaps.

• Statistical reporting

• Continuous variables: medians/IQR; binary outcomes: percentages with Wilson CIs; difference‑in‑differences for comparative analyses; two‑sided α=0.05.

External evidence that guides our targets

• Burden of chronic conditions and need for navigation

• In 2023, an estimated 51.4% of U.S. adults (≈131M) had multiple chronic conditions; prevalence among older adults reached 93%, underscoring navigation needs across the life course (CDC PCD, 2025).

• Policy underpinning insured navigation

• CMS created PIN HCPCS codes G0023/G0024 and peer‑support codes G0140/G0146 to reimburse monthly navigation for serious/high‑risk conditions under physician supervision, with defined documentation and training standards (AAFP; Rural Health Info).

• Impact of navigation on utilization and cost

• NavSTAR patient navigation for hospitalized patients with substance use disorders reduced inpatient days (12.0 vs 15.2) and ED visits (6.1 vs 9.4), producing net savings of ~$17,780 per participant over 12 months (navigation cost ≈$343) (NavSTAR cost‑effectiveness, 2022).

• Oncology navigation programs report reduced unnecessary acute care and high satisfaction; for example, Thyme Care reports a 15–20% reduction in acute care spend and 9/10 satisfaction in cancer populations (vendor‑reported outcomes) (Thyme Care).

• Navigation models for dementia and cross‑sector care

• Scoping review of dementia navigation identified common core services (referrals, education, care planning), barriers (navigator burnout), and facilitators (formal partnerships, flexible delivery) (Dementia navigation review, 2023).

• Cross‑sector coordination review highlighted effective elements: systematic needs assessment, frequent engagement, and standardized protocols—principles we incorporate into Aviator workflows (Cross‑sector coordination, 2022).

Reporting cadence and versioning

• Baseline period: Q4 2025 (October 1–December 31, 2025).

• First public KPI release: Q1 2026 (target publication by April 30, 2026).

• Frequency: Quarterly; annual roll‑up with methods appendix each January.

• Change management: We will document any metric definition changes, cohort re‑cuts, or source system adjustments in a published changelog on this page.

Compliance, privacy, and ethics

• All reporting is HIPAA‑compliant and de‑identified. We suppress small cells and avoid public release of any data that could reasonably re‑identify individuals.

• For comparative evaluations with external data, Aviator executes BAAs/DUAs and, when required by partners, seeks IRB review or exemption.

• We align with CMS guidance for PIN services on qualifications, documentation, and patient consent. Where cost‑sharing applies under Medicare rules, navigators provide plain‑language explanations consistent with CMS policy (AAFP PIN overview).

How partners can participate

• Data collaboration: Payers and providers can supply claims/EHR extracts (standard HL7/FHIR/flat files) to enable robust matched‑cohort analyses.

• Program evaluation: We offer difference‑in‑differences and interrupted time‑series designs, with shared pre‑spec analysis plans and transparent codebooks.

• Community impact: We integrate social care networks and confirm SDOH resolutions with community partners to quantify whole‑person outcomes.

References (selected)

• CDC. Trends in multiple chronic conditions, 2013–2023 (PCD, 2025). https://www.cdc.gov/pcd/issues/2025/24_0539.htm

• AAFP. Medicare PIN codes G0023, G0024, G0140, G0146 (2024). https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/g0023-g0024-g0140-g0146-PIN-codes.html

• Rural Health Information Hub. Principal Illness Navigation services (2024). https://www.ruralhealthinfo.org/care-management/principal-illness-navigation-services

• Englander H et al. NavSTAR cost‑effectiveness (2022). https://pmc.ncbi.nlm.nih.gov/articles/PMC9382857/

• Barken R et al. Dementia navigation scoping review (2023). https://pmc.ncbi.nlm.nih.gov/articles/PMC10578521/

• Chuang E et al. Cross‑sector care coordination review (2022). https://pmc.ncbi.nlm.nih.gov/articles/PMC8861924/

• Thyme Care outcomes (vendor‑reported). https://www.thymecare.com