Governance & Public Reporting – eBrightHealth ACO

ACO Name and Location

Christiana Care Quality Partners ACO, LLC
4755 Ogletown-Stanton Road
Newark, DE 19718

ACO Primary Contact:
Tony Reed
302-428-2105
anthony.reed@christianacare.org

Organizational Information

ACO Participants:

ACO Participants	ACO Participant in Joint Venture
Curtis Smith	N
Westside Family Healthcare, Inc.	N
Bayhealth Medical Center, Inc.	N
Christiana Care Health Services, Inc	N
DOVER FAMILY PHYSICIANS PA	N
QUALITY FAMILY PHYSICIANS, PA	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
Tony	Bianchetta	Member/Med-Peds Physician/Primary Care Leader	8.333	ACO Participant Representative	Christiana Care Health Services, Inc.
Christine	Donohue-Henry	President/Chief Population Health Officer	8.337	ACO Participant Representative	Christiana Care Health Services, Inc.
Preeti	Gupta	Member/Family Medicine Physician	8.333	ACO Participant Representative	Bayhealth Medical Center, Inc.
Evelyn	Hayes	Member/Medicare Beneficiary Representative	8.333	Medicare Beneficiary Representative	N/A
David	Lainoff	Member/Internal Medicine Physician and Care Standardization & CMS Contracts Clinical Director	8.333	ACO Participant Representative	Christiana Care Health Services, Inc.
Lisa	Maxwell	Member/President, Medical Group	8.333	ACO Participant Representative	Christiana Care Health Services, Inc.
Robert	McMurray	Member/Chief Financial Officer	8.333	ACO Participant Representative	Christiana Care Health Services, Inc.
Sharad	Patel	Member/Family Medicine Physician	8.333	ACO Participant Representative	Dover Family Physicians PA
Gary	Siegelman	Member/Senior VP and Chief Medical Officer	8.333	ACO Participant Representative	Bayhealth Medical Center, Inc.
Kenneth	Silverstein	Member/Chief Clinical Officer and Executive VP	8.333	ACO Participant Representative	Christiana Care Health Services, Inc.
Thomas	Stephens	Member/Chief Medical Officer	8.333	ACO Participant Representative	Westside Family Healthcare, Inc.
Kathy	Willey	Member/Family Medicine Physician	8.333	ACO Participant Representative	Christiana Care Health Services, Inc.

Key ACO Clinical and Administrative Leadership:

ACO Executive: Tony Reed
Medical Director: Rose Kakoza
Compliance Officer: Erin Witkosky
Quality Assurance/Improvement Officer: Michelle Adams

Associated Committees and Committee Leadership:

Committee Name	Committee Leader Name and Position
Quality Improvement Committee	Michelle Adams, Director of Ambulatory Quality
ACO Compliance Committee	Erin Witkosky, ACO Compliance Officer

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 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

Shared Savings Distribution

Second Agreement Period
- 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

Quality Performance Results

2021 Quality Performance Results:
Quality performance results are based on CMS Web Interface.

Measure #	Measure Name	Rate	ACO Mean
001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control	9.68	12.46
134	Preventative Care and Screening: Screening for Depression and Follow-up Plan	89.02	74.38
236	Controlling High Blood Pressure	73.06	74.87
318	Falls: Screening for Future Fall Risk	95.44	87.03
110	Preventative Care and Screening: Influenza Immunization	89.59	80.52
226	Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention	96.15	80.97
113	Colorectal Cancer Screening	84.06	73.63
112	Breast Cancer Screening	86.52	75.11
438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	93.28	84.24
479	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups	0.1525	0.1540
MCC1	All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions for ACOs (MCC)	37.75	33.94
CAHPS-1	Getting Timely Care, Appointments, and Information	80.23	84.67
CAHPS-2	How Well Providers Communicate	91.33	93.56
CAHPS-3	Patient’s Rating of Provider	90.53	92.19
CAHPS-4	Access to Specialists	68.93	78.80
CAHPS-5	Health Promotion and Education	72.72	61.61
CAHPS-6	Shared Decision Making	61.88	60.89
CAHPS-7	Health Status and Functional Status	72.75	71.78
CAHPS-8	Care Coordination	83.81	85.66
CAHPS-9	Courteous and Helpful Office Staff	89.39	91.88
CAHPS-11	Stewardship of Patient Resources	25.33	24.71

Please note, the Quality ID #: 370 Depression Remission at 12 months quality measure is not included in public reporting due to low sample size.

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.

If you are an ACO Participant and would like to receive a copy of any of the ACO’s Policies, please click here to request.