Governance & Public Reporting – eBrightHealth ACO

ACO Name and Location

Christiana Care Quality Partners ACO, LLC
4000 Nexus Drive
Wilmington, DE 19803

ACO Primary Contact:

Donna Antenucci
302-463-4873
donna.antenucci@christianacare.org

Organizational Information

ACO Participants:

ACO Participants	ACO Participant in Joint Venture
Aspira Health	N
Bayhealth Medical Center, Inc.	N
Christiana Care Health Initiatives	N
Christiana Care Health Services, Inc	N
Curtis Smith	N
Dover Family Physicians PA	N
Westside Family Healthcare, Inc.	N

ACO Governing Body:

Member First Name	Member Last Name	Member Title/Position	Member’s Voting Power (Expressed as a percentage)	Membership Type	ACO Participant Legal Business Name, if applicable
Priya	Dixit-Patel	Family Medicine Physician	9.09	ACO Participant Representative	Christiana Care Health Services, Inc.
Christine	Donohue-Henry	Chief Population Health Officer	9.1	ACO Participant Representative	Christiana Care Health Services, Inc.
Rebecca	Ford	Population Health Director of Finance	9.09	ACO Participant Representative	Christiana Care Health Services, Inc.
Preeti	Gupta	Family Medicine Physician	9.09	ACO Participant Representative	Bayhealth Medical Center, Inc.
Evelyn	Hayes	Medicare Beneficiary Representative	9.09	ACO Participant Representative	N/A
David	Lainoff	Family Medicine Physician	9.09	ACO Participant Representative	Christiana Care Health Services, Inc.
Sharad	Patel	Family Medicine Physician	9.09	ACO Participant Representative	Dover Family Physicians PA
Bradley	Sandella	Physician	9.09	ACO Participant Representative	Christiana Care Health Services, Inc.
Gary	Siegelman	Chief Medical Officer	9.09	ACO Participant Representative	Bayhealth Medical Center, Inc.
Thomas	Stephens	Chief Medical Officer	9.09	ACO Participant Representative	Westside Family Healthcare, Inc.
Kathy	Willey	Family Medicine Physician	9.09	ACO Participant Representative	Christiana Care Health Services, Inc.
Vacancies (5)

Key ACO Clinical and Administrative Leadership:

ACO Executive: Christine Donohue-Henry
Medical Director: Rose Kakoza
Compliance Officer: Erin Witkosky
Quality Assurance/Improvement Officer: Melissa Myers

Associated Committees and Committee Leadership:

Committee Name	Committee Leader Name and Position
ACO Compliance	Erin Witkosky, ACO Compliance Officer
Clinical Integration & Performance	David Lainoff and Preeti Gupta, Co-Chairs, Family Medicine Physicians
Information Technology & Analytics	Kathy Willey, Chair, Family Medicine Physician
Financing & Contracting	Rebecca Ford, Chair, VP Finance Population Health/Business Planning

Types of ACO Participants, or Combinations of Participants, That Formed the ACO

Federally Qualified Health Center (FQHC)
ACO professionals in a group practice arrangement
Hospital employing ACO professionals

Shared Savings and Losses

Amount of Shared Savings/Losses

Second Agreement Period
- Performance Year 2023, $1,160,540
- Performance Year 2022, $4,659,793
- Performance Year 2021, $3,445,695
- Performance Year 2020, $9,573,291
- Performance Year 2019, $0
First Agreement Period
- Performance Year 2019, $0
- Performance Year 2018, $0
- Performance Year 2017, $0
- Performance Year 2016, $0

Note: Our ACO participated in multiple performance years during Calendar Year 2019. The shared savings/losses amount reported for Performance Year 2019 therefore represents net shared savings or losses across all performance years in 2019 and is shown under all agreement periods in which the ACO operated during Calendar Year 2019.

Shared Savings Distribution

Second Agreement Period
- Performance Year 2023
  - Proportion invested in infrastructure: 10%
  - Proportion invested in redesigned care processes/resources: 40%
  - Proportion of distribution to ACO participants: 50%
- Performance Year 2022
  - Proportion invested in infrastructure: 0%
  - Proportion invested in redesigned care processes/resources: 0%
  - Proportion of distribution to ACO participants: 100%
- Performance Year 2021
  - Proportion invested in infrastructure: 0%
  - Proportion invested in redesigned care processes/resources: 0%
  - Proportion of distribution to ACO participants: 100%
- Performance Year 2020
  - Proportion invested in infrastructure: 0%
  - Proportion invested in redesigned care processes/resources: 0%
  - Proportion of distribution to ACO participants: 100%
- Performance Year 2019
  - Proportion invested in infrastructure: NA
  - Proportion invested in redesigned care processes/resources: NA
  - Proportion of distribution to ACO participants: NA
First Agreement Period
- Performance Year 2019
  - Proportion invested in infrastructure: NA
  - Proportion invested in redesigned care processes/resources: NA
  - Proportion of distribution to ACO participants: NA
- Performance Year 2018
  - Proportion invested in infrastructure: NA
  - Proportion invested in redesigned care processes/resources: NA
  - Proportion of distribution to ACO participants: NA
- Performance Year 2017
  - Proportion invested in infrastructure: NA
  - Proportion invested in redesigned care processes/resources: NA
  - Proportion of distribution to ACO participants: NA
- Performance Year 2016
  - Proportion invested in infrastructure: NA
  - Proportion invested in redesigned care processes/resources: NA
  - Proportion of distribution to ACO participants: NA

Note: Our ACO participated in multiple performance years during Calendar Year 2019. The distribution of shared savings reported for Performance Year 2019 therefore represents the distribution of the net shared savings across all performance years in 2019 and is shown under all agreement periods in which the ACO operated during Calendar Year 2019.

Quality Performance Results

2023 Quality Performance Results:
Quality performance results are based on the CMS Web Interface collection type.

Measure #	Measure Name	Collection Type	Rate	Current Year Mean Performance Rate (SSP ACOs)
001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control	CMS Web Interface	6.96	9.84
134	Preventative Care and Screening: Screening for Depression and Follow-up Plan	CMS Web Interface	89.71	80.97
236	Controlling High Blood Pressure	CMS Web Interface	80.69	77.80
318	Falls: Screening for Future Fall Risk	CMS Web Interface	95.02	89.42
110	Preventative Care and Screening: Influenza Immunization	CMS Web Interface	83.42	70.76
226	Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention	CMS Web Interface	80.77	79.29
113	Colorectal Cancer Screening	CMS Web Interface	77.91	77.14
112	Breast Cancer Screening	CMS Web Interface	88.96	80.36
438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS Web Interface	93.23	87.05
370	Depression Remission at Twelve Months	CMS Web Interface	10.00	16.58
479	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups	Administrative Claims	0.1419	0.1553
484	Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)	Administrative Claims	—	35.39
CAHPS-1	Getting Timely Care, Appointments, and Information	CAHPS for MIPS Survey	80.08	83.68
CAHPS-2	How Well Providers Communicate	CAHPS for MIPS Survey	94.35	93.69
CAHPS-3	Patient’s Rating of Provider	CAHPS for MIPS Survey	90.13	92.14
CAHPS-4	Access to Specialists	CAHPS for MIPS Survey	74.29	75.97
CAHPS-5	Health Promotion and Education	CAHPS for MIPS Survey	70.85	63.93
CAHPS-6	Shared Decision Making	CAHPS for MIPS Survey	59.26	61.60
CAHPS-7	Health Status and Functional Status	CAHPS for MIPS Survey	75.68	74.12
CAHPS-8	Care Coordination	CAHPS for MIPS Survey	84.69	85.77
CAHPS-9	Courteous and Helpful Office Staff	CAHPS for MIPS Survey	91.85	92.31
CAHPS-11	Stewardship of Patient Resources	CAHPS for MIPS Survey	18.56	26.69

For Previous Years’ Financial and Quality Performance Results, please visit data.cms.gov.

Payment Rule Waivers

Skilled Nursing Facility (SNF) 3-day Rule Waiver:
- Our ACO uses the SNF 3-Day Rule Waiver, pursuant to 42 CFR §425.612.
Waiver for Payment for Telehealth Services:
- Our ACO clinicians provide telehealth services using the flexibilities under 42 CFR §425.612(f) and 42 CFR §425.613.