ACO Name and Location Pinehurst Accountable Care Network, Inc. 5 First Village Drive Pinehurst, North Carolina 28374 ACO Primary Contact Primary Contact Name Jim Faircloth Primary Contact Phone Number 910-235-3002 Primary Contact Email Address jfaircloth@pinehurstmedical.com Organizational Information ACO participants: ACO s ACO in Joint Venture (Enter Y or N) Clinic, PA Y Clinic Inc Y ACO governing body: Last Name Member First Name Title/Position Member's Voting Power Membership Type ACO TIN Legal Business Name/DBA, if Applicable Thornton, Chamberlain, David President 1 vote ACO Robert Secretary/Treasurer 1 vote ACO Riefkohl, Waldemar Medical Director/Surgical Services Antil, Mike Medical Director/Primary Care Grantham, 1 vote ACO 1 vote ACO David 1 vote ACO Stokes, Rusell 1 vote ACO
Lucas, Wayne 1 vote ACO Letizia, Kathy 1 vote ACO Little George Community Stakeholder/Medicare Beneficiary 1 vote Community Stakeholder n/a Key ACO clinical and administrative leadership: Jim Faircloth ACO Executive Michael Antil Medical Director Jim Faircloth Compliance Officer Heidi Regan Quality Assurance/Improvement Officer Associated committees and committee leadership: Executive Committee Committee Name Clinical Quality Committee Finance Committee Data Analytics Committee Compliance Committee Privacy Committee Committee Leader Name and Position David Thornton, - Chair Ward Oakley,, co-chair; Mike Antil,, cochair Robert Chamberlain, - Chair Diane Williams, - Chair Kurt Wohlrab, Chair Wyman McGuirt, Chair Types of ACO participants, or combinations of participants, that formed the ACO: Networks of individual practices of ACO professionals Shared Savings and Losses Amount of Shared Savings/Losses First Agreement Period o Performance Year 2016, $0 o Performance Year 2015, $0
Shared Savings Distribution First Agreement Period o Performance Year 2016 Proportion invested in infrastructure: N/A Proportion invested in redesigned care processes/resources: N/A Proportion of distribution to ACO participants: N/A o Performance Year 2015 Proportion invested in infrastructure: N/A Proportion invested in redesigned care processes/resources: N/A Proportion of distribution to ACO participants: N/A Quality Performance Results 2016 Quality Performance Results: ACO# Measure Name Rate ACO Mean 1 CAHPS: Getting Timely Care, Appointments, and Information 85.98 79.9 2 CAHPS: How Well Your Providers Communicate 93.83 92.63 3 CAHPS: Patients' Rating of Provider 92.9 91.93 4 CAHPS: Access to Specialists 85.42 83.52 5 CAHPS: Health Promotion and Education 61.09 60 6 CAHPS: Shared Decision Making 78.13 75.28 7 CAHPS: Health Status/Functional Status 74.55 71.82 34 CAHPS: Stewardship of Patient Resources 33.76 27.52 8 Risk-Standardized, All Condition Readmission 14.87 14.7 35 36 37 38 Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM) 17.74 18.17 All-Cause Unplanned Admissions for Patients with Diabetes 54.03 53.2 All-Cause Unplanned Admissions for Patients with Heart Failure 74.02 75.23 All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions 56.67 59.81 9 Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary Disease or Asthma in Older Adults (AHRQ Prevention Quality Indicator (PQI) 8.83 9.27
10 #5) Ambulatory Sensitive Conditions Admissions: Heart Failure (AHRQ Prevention Quality Indicator (PQI) #8 ) 17.33 14.53 11 39 13 14 15 Percent of PCPs who Successfully Meet Meaningful Use Requirements 100 82.72 Documentation of Current Medications in the Medical Record 98.36 87.54 Falls: Screening for Future Fall Risk 88.1 64.04 Preventive Care and Screening: Influenza Immunization 89.24 68.32 Pneumonia Vaccination Status for Older Adults 91.01 69.21 16 17 18 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow Up Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Preventive Care and Screening: Screening for Clinical Depression and Followup Plan 82.33 74.45 98.06 90.98 62.35 53.63 19 20 Colorectal Cancer Screening 82.47 61.52 Breast Cancer Screening 75.4 67.61 21 Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented 84.21 76.84 42 27 41 28 30 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease 85.53 77.72 Diabetes Mellitus: Hemoglobin A1c Poor Control 7.66 18.24 Diabetes: Eye Exam 52.02 44.94 Hypertension (HTN): Controlling High Blood Pressure 70.14 70.52 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 89.57 85.05 31 33 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for patients with CAD and Diabetes or Left Ventricular Systolic Dysfunction (LVEF<40%) 95.1 88.67 89.42 79.67
Please note, the 40 Depression Remission at 12 months quality measure is not included in public reporting due to low samples. For 2016 Quality Performance Results please visit: https://data.cms.gov/special-programs- Initiatives-Medicare-Shared-Savin/2016-Shared-Savings-Program-SSP-Accountable-Care- O/3jk5-q6dr/data For 2015 Quality Performance Results please visit: https://data.cms.gov/special-programs- Initiatives-Medicare-Shared-Savin/Medicare-Shared-Savings-Program-Accountable-Care-O/x8vaz7cu Note: In the Quality Performance Results file(s) above, search for Pinehurst Accountable Care Network, Inc. or "PACN" to view the quality performance results. This ACO can also be found by using the ACO ID A25744 in the public use files on data.cms.gov. Payment Rule Waivers No, our ACO does not use the SNF 3-Day Rule Waiver.