ACO Name and Location SJFI, LLC dba Oklahoma Health Initiatives St. John Administration 1923 S. Utica Ave Tulsa, OK 74104 ACO Primary Contact Ann Paul, MPH ACO President OKHI@sjmc.org 918.744.2180 Organizational Information ACO Participants: Jane Phillips Memorial Medical Center, Inc. Owasso Medical Facility, Inc. dba St John Owasso St. John Broken Arrow, Inc St. John Medical Center Inc St. John Sapulpa, Inc. Elite Medical Care PLLC dba Elite Medical Clinic Gemini Medical Group Inc Harvard Family Physicians P C James Russell Inc Muskogee Medical and Surgical Associates, LLC Northeast Oklahoma Physician Network Inc St. John Physicians Inc St John Urgent Care Clinics Inc No participants are involved in a joint venture between ACO professionals or hospitals. SJFI ACO Governing Body: Member Last Name Member First Name Member Title/Position Member's Voting Power Membership Type ACO Participant TIN Legal Name Kenagy, Hoffman, Robert Todd Manager, Chairman Manager, Vice- Chairman 1 ACO Participant 1 ACO Participant Beebe, James Manager 1 ACO Participant Inc. Inc. Muskogee Medical & Surgical Associates
Bumpus, Leblanc, Moore, CPA Olsen, PhD LPC Michael Manager 1 ACO Participant Joe Manager 1 ACO Beneficiary N/A Mike Manager 1 ACO Participant (Hosp) Milton Manager 1 ACO Beneficiary N/A Inc.(Gemini Medical Group Inc) Jane Phillips Memorial Medical Center, Inc. Phillips, David Manager 1 ACO Participant (Hosp) Rylander, Edward Manager 1 ACO Participant Sholl, David Manager 1 ACO Participant Owasso Medical Facility, Inc. Inc. Harvard Family Physicians P C SJFI Key ACO Clinical and Administrative Leadership: ACO President Ann Paul, MPH ACO Vice President Robert Kenagy, ACO Secretary Todd Hoffman, ACO Treasurer Lex Anderson, CPA ACO Compliance Official Kevin Steck ACO Medical Director Tobie Bresloff,, St. John Physicians, Inc. SJFI ACO Committees and Committee Leaderships: Board of Managers - Chair, Robert Kenagy, Nominations & Elections Committee - Chair, Robert Kenagy, Quality Improvement Committee Chair, Todd Hoffman, Finance & Operations Committee Chair, Mike Moore, CPA Population Health and Care Pathways Committee Chair, Mark Trimble, Community and Communications Advisory Committee Chair, Milton Olsen, PhD LPC Types of ACO Participants, or Combination of Participants, that Formed the ACO: Oklahoma Health Initiatives is formed with a composition of multiple, otherwise independent ACO participants which consist of ACO professionals in a group practice environment, individual practices of ACO professionals, ACO participants that are hospitals, and an ACO participant that is a critical access hospital. SJFI, LLC dba Oklahoma Health Initiatives ( OKHI ) was formed specifically for submission of an application to provide coordinated care to Medicare beneficiaries who are not enrolled through other Medicare shared savings (or other innovation) programs or Medicare Advantage
plans. The OKHI model provides ACO Participants with the motive and means for collaborating through shared electronic health records and a physician-driven committee governance structure to improve the care and reduce the cost trend for patients. While initially for Medicare beneficiaries, the program expanded to serve other populations as well. The OKHI patient care model envisions a person-centered approach to healthcare emphasizing prevention and wellness, chronic disease management, and better care coordination across the full continuum of care with each Medicare beneficiary as an active participant in his or her care coordination. We seek to improve the health status of each patient in a manner that spends health care dollars wisely and effectively. OKHI is wholly owned by Utica Services Inc which is a subsidiary of St. John Health System ( St. John ) - a tax-exempt, non-profit integrated health delivery system. Utica Services Inc is the sole member of OKHI. OKHI is established as a for-profit limited liability company whose board of directors consists predominantly of physicians and includes at least one Medicare beneficiary. The mission of St. John Health System is that We commit ourselves to serving all persons with special attention to those who are poor and vulnerable. Our Catholic health ministry is dedicated to spiritually centered, holistic care which sustains and improves the health of individuals and communities... Our promise to our patients is to provide Medical Excellence and Compassionate Care. The goals of the ACO are consistent with this mission and are further supported through the organizational vision which states that our ministry will lead to the transformation of healthcare. We will ensure service that is committed to health and well-being for our communities and that responds to the needs of individuals throughout the life cycle. Shared Savings and Losses Amount of Shared Savings/Losses: Performance Year 1: 1 Not in operations Performance Year 2014: $0 Performance Year 2015: Not yet determined Performance Year 2016: Not yet determined How Shared Savings Are Distributed: ACO Physicians = 50% ACO Hospitals = 15% Reinvestment in infrastructure = 20% ACO Affiliates = 15% distributed as performance improvement incentive 1 Performance Year 1 for Shared Savings Program ACOs includes a 21- or 18-month period for ACOs with 2012 start dates and a 12-month period for ACOs with 2013 start dates.
Quality Performance Results Table 2012 Reporting Period 2013 Reporting Period 2014 Reporting Period Measure number Performance measure 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 Getting Timely Care, Not in operations Not in operations Not in operations Not in operations 75.85 80.13 Appointments, and Information ACO #2 How Well Your Doctors Not in operations Not in operations Not in operations Not in operations 91.37 92.39 Communicate ACO #3 Patients Rating of Doctor Not in operations Not in operations Not in operations Not in operations 90.35 91.58 ACO #4 Access to Specialists Not in operations Not in operations Not in operations Not in operations 83.82 83.97 ACO #5 Health Promotion and Not in operations Not in operations Not in operations Not in operations 53.32 58.29 Education ACO #6 Shared Decision Making Not in operations Not in operations Not in operations Not in operations 74.08 74.60 ACO #7 Health Status/Functional Not in operations Not in operations Not in operations Not in operations 68.69 71.10 Status ACO #8 Risk Standardized, All Not in operations Not in operations Not in operations Not in operations 15.37 15.15 Condition Readmissions ACO #9 ASC Admissions: COPD or Not in operations Not in operations Not in operations Not in operations 1.08 1.08 Asthma in Older Adults ACO #10 ASC Admission: Heart Not in operations Not in operations Not in operations Not in operations 0.93 1.19 Failure ACO #11 Percent of PCPs who Not in operations Not in operations Not in operations Not in operations 73.12 76.71 Qualified for EHR Incentive Payment ACO #12 Medication Reconciliation Not in operations Not in operations Not in operations Not in operations 87.45 82.61 ACO #13 Falls: Screening for Fall Not in operations Not in operations Not in operations Not in operations 7.1 45.60 Risk ACO #14 Influenza Immunization Not in operations Not in operations Not in operations Not in operations 55.86 57.51 ACO #15 Pneumococcal Not in operations Not in operations Not in operations Not in operations 37.29 55.03 Vaccination ACO #16 Adult Weight Screening Not in operations Not in operations Not in operations Not in operations 52.75 66.75 and Follow-up ACO #17 Tobacco Use Assessment Not in operations Not in operations Not in operations Not in operations 95.17 86.79 and Cessation Intervention ACO #18 Depression Screening Not in operations Not in operations Not in operations Not in operations 2.67 39.27 ACO #19 Colorectal Cancer Not in operations Not in operations Not in operations Not in operations 45.47 56.14 Screening ACO #20 Mammography Screening Not in operations Not in operations Not in operations Not in operations 50.17 61.41
ACO #21 Proportion of Adults who had blood pressure screened in past 2 years ACO #22 Hemoglobin A1c Control (HbA1c) (<8 percent) ACO #23 Low Density Lipoprotein (LDL) (<100 mg/dl) ACO #24 Blood Pressure (BP) < 140/90 ACO Information Required to be Published on ACO Website per CMS Regulations Not in operations Not in operations Not in operations Not in operations 51.14 60.24 Not in operations Not in operations Not in operations Not in operations 70.15 N/A Not in operations Not in operations Not in operations Not in operations 47.05 N/A Not in operations Not in operations Not in operations Not in operations 64.76 N/A ACO #25 Tobacco Non Use Not in operations Not in operations Not in operations Not in operations 86.85 N/A ACO #26 Aspirin Use Not in operations Not in operations Not in operations Not in operations 65.43 N/A ACO #27 Percent of beneficiaries Not in operations Not in operations Not in operations Not in operations 21.68 20.35 with diabetes whose HbA1c in poor control (>9 percent) ACO #28 Percent of beneficiaries Not in operations Not in operations Not in operations Not in operations 66.22 68.02 with hypertension whose BP < 140/90 ACO #29 Percent of beneficiaries Not in operations Not in operations Not in operations Not in operations 50.55 57.29 with IVD with complete lipid profile and LDL control < 100mg/dl ACO #30 Percent of beneficiaries Not in operations Not in operations Not in operations Not in operations 81.39 80.79 with IVD who use Aspirin or other antithrombotic ACO #31 Beta-Blocker Therapy for Not in operations Not in operations Not in operations Not in operations 85.44 82.71 LVSD ACO #32 Drug Therapy for Not in operations Not in operations Not in operations Not in operations 61.23 N/A Lowering LDL Cholesterol ACO #33 ACE Inhibitor or ARB Therapy for Pts w/cad & Diabetes and/or LVSD Not in operations Not in operations Not in operations Not in operations 69.88 N/A Note: ASC = ambulatory sensitive conditions, COPD = chronic obstructive pulmonary disease, PCP = primary care physician, EHR = electronic health record, IVD = ischemic vascular disease, LVSD = left ventricular systolic dysfunction, ACE = angiotensin-converting enzyme, ARB = angiotensin receptor blocker, CAD = coronary artery disease.
Medicare Shared Savings Program Waiver Disclosures (arrangements for which waiver protection is sought) This ACO has an agreement with each of its ACO Participants to participate in the Medicare Shared Savings Program. There are certain other arrangements among ACO Participants and ACO Affiliates, including St. John Medical Center, Harvard Family Physicians, Stewart Katz,, James Russell,, and Nephrology Associates, Inc regarding the support of electronic health records software and related services that qualify under the pre-participation or participation waivers issued by the Centers for Medicare and Medicaid Services and the Office of the Inspector General, Department of Health and Human Services, Sec. 76 Fed. Reg. p.67992 Nov. 2, 2011 and Sec. 80 Fed. Reg. p. 66727 Oct. 29, 2015. The ACO has arranged for the regional Health Information Exchange, MyHealth Access Network to create and support the use of a Secure Direct Messaging account for those ACO Participants, ACO Affiliates, and other providers that did not have access to a Secure Direct Messaging account for the purpose of communicating Transition of Care and other health related documents and data with the provider during the course of patient care. The provision regarding the support of the Secure Direct Messaging related services qualify under the pre-participation or participation waivers issued by the Centers for Medicare and Medicaid Services and the Office of the Inspector General, Department of Health and Human Services, Sec. 76 Fed. Reg. p.67992 Nov. 2, 2011 and Sec. 80 Fed. Reg. p. 66727 Oct. 29, 2015. A demonstration project has been established by an ACO Participant, St. John Medical Center, which has arranged for transportation assistance of certain patients to be provided by Morton Comprehensive Health Center (a federally qualified health center) as an independent contractor. Such services are approved on a case-by-case basis to established patients of St. John Medical Center who are among underserved populations. These transportation services qualify under the pre-participation or participation or patient incentive waivers issued by the Centers for Medicare and Medicaid Services and the Office of the Inspector General, Department of Health and Human Services, Sec. 76 Fed. Reg. p.67992 and 68001 Nov. 2, 2011 and Sec. 80 Fed. Reg. p. 66727 Oct. 29, 2015.