Caravan Health ACO 41 LLC

ACO Name and Location

Caravan Health ACO 41 LLC
dba Avera Prairie View ACO
7509 NW Tiffany Springs Parkway
Ste. 310
Kansas City, Missouri 64153

Primary Contact Name	Teri Bergeleen
Primary Contact Phone Number	605-322-4576
Primary Contact Email Address	Teri.Bergeleen@avera.org

ACO participants:

ACO Participants	ACO Participant in Joint Venture
Avera Marshall	Y
Avera McKennan	Y
City of Brookings	N
Heart Hospital of South Dakota LLC	Y
Avera St. Marys	Y
Avera St. Lukes	Y
Avera Queen of Peace	Y
Lakes Regional Hospital	Y
Floyd Valley Hospital	Y
Spencer Municipal Hospital	Y
Rural Health Care Inc	Y
Anesthesiology Associates, Inc.	N
Midwest Ear, Nose & Throat Associates PC	N
Northwest Iowa Urologist OC	N
NWIA Bone, Joint & Sports Surgeons, PC	N
Northwest Iowa Ear Nose and Throat PC	N
Opthalmology LTD	N
Surgical Institute of South Dakota PC	N
Midwest Radiology and Imaging PC	N
Ophthalmology LTD Eye Surgery Center LLC	N
Northwest Iowa Surgeons PC	N
Northwest Iowa Anesthesia Associates	N
Physicians Laboratory, LTD.	N
Physicians Laboratory of Northwest Iowa LTD	N
USC Ambulatory Surgical Center Prof LLC	N
Urology Specialists Chartered	N
Yankton Medical Clinic PC	N
Sacred Heart Health Services	Y
Avera At Home	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
Debbie	Streier	Board Member	7.692%	ACO Participant Representative	Avera Marshall
Shantel	Krebs	Board Member	7.692%	ACO Participant Representative	Avera St. Marys
David	Flicek	Board Member	7.692%	ACO Participant Representative	Avera Mckennan
Brenda	Tiefenthaler	Board Member	7.692%	ACO Participant Representative	Spencer Municipal Hospital
David	Basel, MD	Board Member	7.692%	ACO Participant Representative	Avera McKennan
Doug	Ekeren	Board Member	7.692%	ACO Participant Representative	Sacred Heart Health Services
Dan	Bjerkness	Board Member	7.692%	ACO Participant Representative	Avera St. Luke
Michael	Gibbs	Board Member	7.692%	ACO Participant Representative	Heart Hospital of South Dakota LLC
Jim	Hardwick	Board Member	7.692%	ACO Participant Representative	Rural Health Care Inc.
Jeremy	Bolluyt	Board Member	7.692%	ACO Participant Representative	Lakes Regional Healthcare
Dustin	Wright	Board Member	7.692%	ACO Participant Representative	Floyd Valley
Susan	Fanta, MD	Board Member	7.692%	ACO Participant Representative	Yankton Medical Clinic
Patrick	Clark	Board Member	7.692%	ACO Medicare Beneficiary	Avera Queen of Peace
Hilary	Rockwell	Board Member	7.692%	ACO Participant Representative	Avera Queen of Peace
Teri	Bergeleen	Board Member	0%	N/A	N/A

Due to rounding, ‘Member’s Voting Power’ may not equal 100 percent.

Key ACO clinical and administrative leadership:

David Flicek	ACO Executive
Dr. David Basel	Medical Director
T. Gregory	Compliance Officer
Eric Boyce	Quality Assurance/Improvement Officer

Associated committees and committee leadership:

Committee Name	Committee Leader Name and Position
Executive Committee	David Flicek-Chairman
Steering Committee	David Basel, MD- Vice-Chairman

Types of ACO participants, or combinations of participants, that formed the ACO:

Partnerships or joint venture arrangements between hospitals and ACO professionals
Hospital employing ACO professionals
Critical Access Hospital (CAH) billing under Method II

Amount of Shared Savings/Losses

First Agreement Period
- Performance Year 2019, $0
- Performance Year 2020, $0
- Performance Year 2021, $0
- Performance Year 2022, $0

Shared Savings Distribution

Quality performance results are based on CMS Web Interface.

Measure #	Measure Name	Collection Type	Rate	ACO Mean
001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control [1]	CMS Web Interface	7.82	10.71
134	Preventative Care and Screening: Screening for Depression and Follow-up Plan	CMS Web Interface	77.44	76.97
236	Controlling High Blood Pressure	CMS Web Interface	71.10	76.16
318	Falls: Screening for Future Fall Risk	CMS Web Interface	98.81	87.83
110	Preventative Care and Screening: Influenza Immunization	CMS Web Interface	74.90	77.34
226	Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention	CMS Web Interface	81.82	79.27
113	Colorectal Cancer Screening	CMS Web Interface	80.48	75.32
112	Breast Cancer Screening	CMS Web Interface	79.04	78.07
438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS Web Interface	84.88	86.37
370	Depression Remission at Twelve Months	CMS Web Interface	15.69	16.03
321	CAHPS for MIPS [3]	CMS Web Interface	N/A	N/A
479	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups [1]	CMS Web Interface	0.1302	0.1510
484	Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions [1]	CMS Web Interface	33.19	30.97

For Previous Years’ Financial and Quality Performance Results, Please Visit data.cms.gov.

Skilled Nursing Facility (SNF) 3-Day Rule Waiver:
- Our ACO uses the SNF 3-Day Rule Waiver, pursuant to 42 CFR § 425.612.