Peninsula Regional Clinically Integrated Network

ACO Name and Location

Peninsula Regional Clinically Integrated Network, LLC

100 East Carroll St

Salisbury, MD 21801

ACO Primary Contact

Courtney Cooper

410-912-5808

courtney.cooper@tidalhealth.org

Organizational Information

ACO Participants

ACO Participants	ACO Participant in Joint Venture
TidalHealth Primary Care, LLC	Y
TidalHealth Physician Network, Inc.	Y

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
Stephen	Robinson	ACO Participant	25%	ACO Participant Representative	TidalHealth Primary Care, LLC
Kathy	Talbot	ACO Participant	12.5%	ACO Participant Representative	N/A
Timothy	Feist	Beneficiary	12.5%	Medicare Beneficiary Representative	N/A
John	Appiott	ACO Participant	25%	ACO Participant	TidalHealth Physician Network, Inc.

Key ACO Clinical and Administrative Leadership:

ACO Executive: Courtney Cooper

Medical Director: James Trumble

Compliance Officer: Debra Sheets

Quality Assurance/Improvement Officer: Courtney Cooper

Associated committees and committee leadership:

Committee Name	Committee Leader Name and Position
Clinical Integration and Quality Improvement Committee	James Trumble, M.D., PRCIN/MSSP ACO Medical Director and Committee Chairman
Compliance Committee	Debra Sheets, Compliance Officer and Committee Chairman
Managed Care Committee	Courtney Cooper, ACO Executive and Committee Chairman
Credentialing Committee	James Trumble, M.D., PRCIN/MSSP ACO Medical Director and Committee Chairman

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

Network of Individual Practices of ACO Professions

Shared Savings and Losses

Amount of Shared Savings/Losses:

Second Agreement Period

Performance Year 2024, $3,448,080
Performance Year 2023, $-23,609.46
Performance Year 2022, $0
Performance Year 2021, $1,730,838.60

Our ACO re-entered the Shared Savings Program in Performance Year 2022 under agreement period 2. Shared savings/losses and shared savings distributions are therefore reported, beginning with this agreement period.

Shared Savings Distribution:

Second Agreement Period

Performance Year 2024

Proportion invested in infrastructure: N/A
Proportion invested in redesigned care processes/resources: 50%
Proportion of distribution to ACO participants: 50%

Performance Year 2023

Proportion invested in infrastructure: N/A
Proportion invested in redesigned care processes/resources: N/A
Proportion of distribution to ACO participants: N/A

Performance Year 2022

Proportion invested in infrastructure: N/A
Proportion invested in redesigned care processes/resources: N/A
Proportion of distribution to ACO participants: N/A

Performance Year 2021

Proportion invested in infrastructure:
Proportion invested in redesigned care processes/resources: 40%
Proportion of distribution to ACO participants: 60%

Quality Performance Results

2024 Quality Performance Results:

Quality performance results are based on the CMS Web Interface & eCQM/MIPS CQM/Medicare CQM collection type.

Measure #	Measure Name	Collection Type	Rate	ACO Mean
Quality ID# 001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control	CMS Web Interface	5.08	9.44
Quality ID# 134	Preventative Care and Screening: Screening for Depression and Follow-up Plan	CMS Web Interface	98.01	81.46
Quality ID# 236	Controlling High Blood Pressure	CMS Web Interface	73.34	79.49
Quality ID# 318	Falls: Screening for Future Fall Risk	CMS Web Interface	96.27	88.99
Quality ID# 110	Preventative Care and Screening: Influenza Immunization	CMS Web Interface	47.26	68.60
Quality ID# 226	Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention	CMS Web Interface	96.15	79.98
Quality ID# 113	Colorectal Cancer Screening	CMS Web Interface	83.87	77.81
Quality ID# 112	Breast Cancer Screening	CMS Web Interface	88.51	80.93
Quality ID# 438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS Web Interface	88.45	86.50
Quality ID# 370	Depression Remission at Twelve Months	CMS Web Interface	54.93	17.35
Quality ID# 321	CAHPS for MIPS	CMS Web Interface	7.00	6.67
Quality ID# 479	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Eligible Clinician Groups	Administrative Claims	0.1413	0.1517
Quality ID# 484	Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions	Administrative Claims	N/A	37.00
Quality ID# 001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)	MIPS CQMs	15.07	-
Quality ID# 134	Preventive Care Screening: Screening for Depression and Follow-up Plan	MIPS CQMs	94.48	-
Quality ID# 236	Controlling High Blood Pressure	MIPS CQMs	72.85	-
CAHPS-1	Getting Timely Care, Appointments, and Information	CAHPS for MIPS Survey	85.64	83.70
CAHPS-2	How Well Providers Communicate	CAHPS for MIPS Survey	94.16	93.96
CAHPS-3	Patient's Rating of Provider	CAHPS for MIPS Survey	94.07	92.43
CAHPS-4	Access to Specialists	CAHPS for MIPS Survey	69.05	75.76
CAHPS-5	Health Promotion and Education	CAHPS for MIPS Survey	74.05	65.48
CAHPS-6	Shared Decision Making	CAHPS for MIPS Survey	65.73	62.31
CAHPS-7	Health Status and Functional Status	CAHPS for MIPS Survey	75.87	74.14
CAHPS-8	Care Coordination	CAHPS for MIPS Survey	85.10	85.89
CAHPS-9	Courteous and Helpful Office Staff	CAHPS for MIPS Survey	92.54	92.89
CAHPS-11	Stewardship of Patient Resources	CAHPS for MIPS Survey	25.58	26.98