A health-center led accountable care organization serving Medicare beneficiaries in the Hudson Valley and New York City.

Governance and Senior Staff

  • ACO Name and Location:
Family Health ACO
2006 Madison Avenue
New York, NY 10035

ACO Primary Contact:

Dan Bowles, Executive Director
dbowles@aledade.com
540- 263-0171

Organizational Information:

  • ACO Participants:
    • Hudson River Healthcare
    • Institute for Family Health
    • Open Door Family Medical Center
  • ACO participants in joint ventures between ACO professionals and hospitals
    • No participants are involved in a joint venture between ACO professionals and hospitals
  • ACO Governing Body:
    • Dr. Neil Calman, Chair & Voting Member, Institute for Family Health
    • Anne Nolon, Vice-Chair & Voting Member, Hudson River Healthcare
    • Lindsay Farrell, Secretary, Treasurer, and Voting Member, Open Door Family Medical Center
    • Pam Ferrari, Voting Member, Open Door Family Medical Center
    • Maxine Golub, Voting Member, Institute for Family Health
    • Carole Furman, Voting Member, Beneficiary Representative
    • Dr. Paul Kaye, Voting Member, Hudson River Healthcare
    • Dr. Robert Schiller, Voting Member, Institute of Family Health
    • Jim Sinkoff, Voting Member, Hudson River Healthcare
    • Dr. Daren Wu, Voting Member, Open Door Family Medical Center
  • Key ACO Clinical and Administrative Leadership:
    • Dan Bowles, Executive Director
    • Dr. Paul Kaye, Chief Medical Officer
    • Maria Mazzotta, Chief Financial Officer
    • Kathy Creswell, Chief Information Officer
    • Dr. Sophia McIntyre, Chief Quality Officer
    • Anita Wilenkin, Chief Compliance Officer
  • Associated Committees and Committee Leadership:
    • Dr. Neil Calman, Board of Managers
    • Anne Nolon, Finance Committee
    • Lindsay Farrell, Analytics & Quality Improvement
  • Types of ACO participants, or combination of participants, that formed the ACO:
    • Federally qualified health centers (FQHCs)

Shared Savings and Losses:

  • Payment Rule Waivers
    • No. Our ACO does not use the SNF 3-Day Rule Waiver
  • Amount of Shared Savings/Losses:
    • Performance Year 2016: N/A
    • Performance Year 2015: $0
    • Performance Year 2014: $0
  • How shared savings are distributed:
    • 100% re-investment

  • Quality Performance Results

Measure Number Measure Name 2015 Reporting Period
ACO Performance Rate Mean performance rate (SSP- ACOs)
ACO-1 CAHPS: Getting Timely Care, Appointments, and Information  75.04 80.61
ACO-2 CAHPS: How Well Your Providers Communicate  90.86 92.65
ACO-3 CAHPS: Patients Rating of Provider  89.39 91.94
ACO-4 CAHPS: Access to Specialists  78.29 83.61
ACO-5 CAHPS: Health Promotion and Education 61.87 59.06
ACO-6 CAHPS: Shared Decision Making  72.36 75.17
ACO-7 CAHPS: Health Status/Functional Status  74.06 72.3
ACO-34 CAHPS: Stewardship of Patient Resources* 22.34 26.87
ACO-8 Risk Standardized, All Condition Readmission 15.92 14.86
ACO-35 Skilled Nursing Facility 30-day All-Cause Readmission measure (SNFRM)* 17.67 18.07
ACO-36 All-Cause Unplanned Admissions for Patients with Diabetes* 57.02 54.6
ACO-37 All-Cause Unplanned Admissions for Patients with Heart Failure* 106.39 76.96
ACO-38 All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions 80.14 62.92
ACO-9 Ambulatory Sensitive Condition Admissions: Chronic Obstructive Pulmonary Disease or Asthma in Older Adults (AHRQ Prevention Quality Indicator (PQI) #5) 1.4 1.11
ACO-10 Ambulatory Sensitive Conditions Admissions: Heart Failure (AHRQ Prevention Quality Indicator (PQI) #8) 1.29 1.04
ACO-11 Percent of PCPs who Successfully Meet Meaningful Use Requirements 0.00% 76.22%
ACO-39 Documentation of Current Medications in the Medical Record* 79.58% 84.07%
ACO-13 Falls: Screening for Future Fall Risk  84.96% 56.46%
ACO-14 Preventive Care and Screening: Influenza Immunization 59.45% 62.03%
ACO-15 Pneumonia Vaccination Status for Older Adults 88.89% 63.73%
ACO-16 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up 86.38% 71.15%
ACO-17 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 98.86% 90.16%
ACO-18 Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan 92.63% 45.25%
ACO-19 Colorectal Cancer Screening 54.76% 60.06%
ACO-20 Breast Cancer Screening 66.41% 65.67%
ACO-21 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented  82.09% 70.04%
ACO-40 Depression Remission at Twelve Months* N/A N/A
ACO-27 Diabetes Mellitus: Hemoglobin A1c Poor Control  18.36% 20.38%
ACO-41 Diabetes: Eye Exam* 49.22% 41.05%
ACO-28 Hypertension: Controlling High Blood Pressure  67.74% 69.62%
ACO-30 Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic 83.64% 83.82%
ACO-31 Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 83.33% 87.22%
ACO-33 Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - for patients with CAD and Diabetes or Left Ventricular Systolic Dysfunction (LVEF<40%) 89.06% 77.73%

CAHPS = Consumer Assessment of Healthcare Providers and Systems, PQI = Prevention Quality Indicator, LVSD = left ventricular systolic dysfunction, ACE = angiotensin-converting enzyme, ARB = angiotensin receptor blocker, CAD = coronary artery disease. *= Measure required beginning Reporting Year 2015. N/A= Reporting on the depression remission measure is not required for 2015, as indicated by N/A



Measure Number Performance Measure 2012 Reporting Period 2013 Reporting Period 2014 Reporting Period
ACO Performance Rate Mean performance rate for all ACOs ACO Performance Rate Mean performance rate for all ACOs ACO Performance Rate Mean performance rate for all ACOs
ACO #1 CAHPS: Getting Timely Care, Appointments, and Information Not in Operations Not in Operations Not in Operations Not in Operations 76.72 80.13
ACO #2 CAHPS: How Well Your Doctors Communicate Not in Operations Not in Operations Not in Operations Not in Operations 91.98 92.39
ACO #3 CAHPS: Patients' Rating of Doctor Not in Operations Not in Operations Not in Operations Not in Operations 91.86 91.58
ACO #4 CAHPS: Access to Specialists Not in Operations Not in Operations Not in Operations Not in Operations 83.99 83.97
ACO #5 CAHPS: Health Promotion and Education Not in Operations Not in Operations Not in Operations Not in Operations 62.35 58.29
ACO #6 CAHPS: Shared Decision Making Not in Operations Not in Operations Not in Operations Not in Operations 74.64 74.6
ACO #7 CAHPS: Health Status/Functional Status Not in Operations Not in Operations Not in Operations Not in Operations 76.22 71.1
ACO #8 Risk Standardized, All Condition Readmissions  Not in Operations Not in Operations Not in Operations Not in Operations 15.2 15.15
ACO #9 Ambulatory Sensitive Condition Admissions: COPD or asthma in Older Adults Not in Operations Not in Operations Not in Operations Not in Operations 1.57 1.08
ACO #10 ASC Admisison: Heart Failure Not in Operations Not in Operations Not in Operations Not in Operations 1.53 1.19
ACO #11 Percent of PCPs who Qualified for EHR Incentive Payment Not in Operations Not in Operations Not in Operations Not in Operations N/A 76.71%
ACO #12 Medication Reconciliiation Not in Operations Not in Operations Not in Operations Not in Operations 74.73% 82.61%
ACO #13 Falls: Screening for Falls Risk Not in Operations Not in Operations Not in Operations Not in Operations 19.92% 45.60%
ACO #14 Influenza Immunization Not in Operations Not in Operations Not in Operations Not in Operations 65.14% 57.51%
ACO #15 Pneumococcal Vaccination Not in Operations Not in Operations Not in Operations Not in Operations 50.10% 55.03%
ACO #16 Adult Weight Screening and Follow-Up Not in Operations Not in Operations Not in Operations Not in Operations 77.95% 66.75%
ACO #17 Tobacco Use Assessment and Cessation Intervention Not in Operations Not in Operations Not in Operations Not in Operations 95.29% 86.79%
ACO #18 Depression Screening Not in Operations Not in Operations Not in Operations Not in Operations 74.60% 39.27%
ACO #19 Colorectal Cancer Screening Not in Operations Not in Operations Not in Operations Not in Operations 59.31% 56.14%
ACO #20 Mammography Screening Not in Operations Not in Operations Not in Operations Not in Operations 54.63% 61.41%
ACO #21 Proportion of Adults who had blood pressure screened in past 2 years Not in Operations Not in Operations Not in Operations Not in Operations 68.85% 60.24%
ACO #22 Hemoglobin A1c Control (HbA1c) (<8 percent) Not in Operations Not in Operations Not in Operations Not in Operations 66.41% N/A
ACO #23 Low Density Lipoprotein (LDL) (<100 mg/dL) Not in Operations Not in Operations Not in Operations Not in Operations 52.67% N/A
ACO #24 Blood Pressure (BP)  <140/90 Not in Operations Not in Operations Not in Operations Not in Operations 71.76% N/A
ACO #25 Tobacco Non Use Not in Operations Not in Operations Not in Operations Not in Operations 84.73% N/A
ACO#26 Aspirin Use Not in Operations Not in Operations Not in Operations Not in Operations 90.91% N/A
ACO #27 Percent of beneficiaries with diabetes whose HbA1c in poor control (>9 percent) Not in Operations Not in Operations Not in Operations Not in Operations 22.14% 20.35%
ACO #28 Percent of beneficiaries with hypertension whose BP <140/90 Not in Operations Not in Operations Not in Operations Not in Operations 69.68% 68.02%
ACO #29 Percent of beneficiaries with IVD with complete lipid profile and LDL control <100 mg/dl Not in Operations Not in Operations Not in Operations Not in Operations 49.01% 57.29%
ACO #30 Percent of beneficaries with IVD who use Aspirin or other antithrombotic  Not in Operations Not in Operations Not in Operations Not in Operations 88.08% 80.79%
ACO #31 Beta-Blocker Therapy for LVSD Not in Operations Not in Operations Not in Operations Not in Operations 100.00% 82.71%
ACO #32 Drug Therapy for Lowering LDL Cholesterol Not in Operations Not in Operations Not in Operations Not in Operations 63.93% N/A
ACO #33 ACE inhibitor or ARB Therapy for Patients with CAD and Diabetes and/or LVSD Not in Operations Not in Operations Not in Operations Not in Operations 88.16% N/A

Media Contacts

Neil Calman
The Institute for Family Health
(212) 633-0800 x1246

Lindsay Farrell
Open Door Family Medical Centers, Inc
(914) 502-1451

Anne Nolon
HRHCare Community Health
(914) 734-8787

Emily Maxson
Aledade
(202) 742-5994