ACO Name and Location

Caravan Health ACO 14 LLC
dba Mountlake ACO
7509 NW Tiffany Springs Parkway
Ste. 310
Kansas City, Missouri 64153

ACO Primary Contact

Primary Contact Name Desiree Brewer
Primary Contact Phone Number 916-542-4582
Primary Contact Email Address

Organizational Information

ACO participants:
ACO Participants ACO Participant in Joint Venture (Enter Y or N)
S. Jeff Bray, DPM, Inc. N
Brandon A West DO PLLC N
Pocatello Hospital LLC N
Pocatello Health Services LLC Y
Life Change Associates Pc N
Robert Jones N
Johnson Memorial Health Services Y
Glencoe Regional Health Services Y
Glacial Ridge Hospital District Y
Northfield Hospital Y
Chippewa County Montevideo Hospital Y
Anthony Joseph, MD Inc. N
Idaho Regional Hand & Upper Extremity Center PLLC N
Firth Medical Center PLLC N
SEI Anesthesia, PLLC N
Specialized Family Medicine N
Mountain View Family Medicine, Inc N
Willow Sage Services LLC N
St. Mary’s Hospital Y
Family Practice Group, P.A. N
Clearwater Valley Hospital & Clinics Inc Y
John Fornarotto Pllc N
Richard A. Wathne, MD PA N
Benjamin Blair, MD PA N
Caribou Memorial Hospital Y
David Parry N
Need-A-Nurse Medical Staffing, LLC Y
ACO governing body:
Member Member’s Voting Power Membership Type ACO Participant TIN
Legal Business Name/DBA, if Applicable
Last Name First Name Title/Position
Underdahl Steve Chairman 1 ACO Participant Representative Northfield Hospital
Kleman Barbara Board Member 1 ACO Participant Representative Chippewa County Montevideo Hospital
Frei Steve Board Member 1 ACO Participant Representative St. Mary's Hospital
Stensrud Kirk Board Member 1 ACO Participant Representative Glacial Ridge Hospital District
Lee Stacey Board Member 1 ACO Participant Representative Johnson Memorial Health Services
Bonner Lenne Board Member 1 ACO Participant Representative Clearwater Valley Hospital and Clinics Inc
Bailey Jordan Vice-Chairman 1 ACO Participant Representative Portneuf Quality Alliance
Edin Scott Secretary/Treasurer 1 ACO Participant Representative Northfield Hospitals and Clinics
Thomas  Christina  Non-Voting Member 0 ACO Participant Representative Caribou Memorial Hospital
Lovdahl Brian Board Member 1 ACO Particiapnt Representative Chippewa County Montevideo Hospital
McGrath  Kelly ACO Medical Director 1 ACO Participant Representative Clearwater Valley Hospital and Clinics, Inc.
Henderson  Patty Board Member 1 ACO Participant Representative Glencoe Regional Health Services
Hall Mark Board Member 1 ACO Participant Representative Mountain View Hospital
Hillyard Ned Board Member 1 ACO Participant Representative  Mountain View Hospital
Kinney George Board Member ACO Medicare Beneficiary
Ethington Shannon Non-Voting Member 0 ACO Participant Representative
Waldbillig Kurt Board Member 1 ACO Participant Representative
Key ACO clinical and administrative leadership:
Jade Jagers ACO Executive
Kelly McGrath, MD Medical Director
Leeann Hastings Compliance Officer
Rayna Caplan Quality Assurance/Improvement Officer
Associated committees and committee leadership:
Committee Name Committee Leader Name and Position
Information Technology Committee Brad Rogers, Chairman
Care Coordination & Patient Engagement Committee Kristin Schultz, Chairman
Evidence-Based Medicine Committee Patricia Freund, MD, Chairman
Finance Committee Jyl Ruland, Chairman
Quality & Performance Improvement Committee Jeff Plemel, Chairman

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

  • Partnerships or joint venture arrangements between hospitals and ACO professionals

Shared Savings and Losses

Amount of Shared Savings/Losses

  • First Agreement Period
    • Performance Year 2018, $0

Shared Savings Distribution

  • First Agreement Period
    • Performance Year 2018
      • 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

2018 Quality Performance Results:
ACO# Measure Name Rate ACO Mean
ACO-1 CAHPS: Getting Timely Care, Appointments, and Information 87.92 86.14
ACO-2 CAHPS: How Well Your Providers Communicate 94.25 93.93
ACO-3 CAHPS: Patients’ Rating of Provider 92.09 92.45
ACO-4 CAHPS: Access to Specialists 84.04 81.50
ACO-5 CAHPS: Health Promotion and Education 56.76 59.26
ACO-6 CAHPS: Shared Decision Making 64.08 61.94
ACO-7 CAHPS: Health Status/Functional Status 70.93 73.35
ACO-34 CAHPS: Stewardship of Patient Resources 29.90 26.26
ACO-8 Risk Standardized, All Condition Readmission 14.99 14.98
ACO-35 Skilled Nursing Facility 30-day All-Cause Readmission measure (SNFRM) 18.60 18.59
ACO-36 All-Cause Unplanned Admissions for Patients with Diabetes 41.93 37.01
ACO-37 All-Cause Unplanned Admissions for Patients with Heart Failure 71.50 76.75
ACO-38 All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions 59.20 59.00
ACO-43 Ambulatory Sensitive Condition Acute Composite (AHRQ Prevention Quality Indicator (PQI) #91) 2.33 1.98
ACO-11 Use of Certified EHR Technology 100.00 98.20
ACO-12 Medication Reconciliation Post-Discharge 79.51 85.91
ACO-13 Falls: Screening for Future Fall Risk 46.40 79.73
ACO-44 Use of Imaging Studies for Low Back Pain 53.85 64.36
ACO-14 Preventive Care and Screening: Influenza Immunization 77.05 72.71
ACO-15 Pneumonia Vaccination Status for Older Adults 76.68 75.97
ACO-16 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow Up 62.50 76.83
ACO-17 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 58.06 72.81
ACO-18 Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan 59.70 66.74
ACO-19 Colorectal Cancer Screening 66.54 68.27
ACO-20 Breast Cancer Screening 66.27 71.96
ACO-42 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease 82.85 81.47
ACO-27 Diabetes Mellitus: Hemoglobin A1c Poor Control 23.83 15.51
ACO-41 Diabetes: Eye Exam 47.66 52.42
ACO-28 Hypertension (HTN): Controlling High Blood Pressure 73.44 73.10
ACO-30 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet 91.60 88.92
Please note, the ACO-40 Depression Remission at 12 months quality measure is not included in public reporting due to low sample size.  
Note: In the Quality Performance Results file(s) above, search for “Caravan Health ACO 14 LLC” or “Mountlake ACO” to view the quality performance results. This ACO can also be found by using the ACO ID A3577 in the public use files on

Payment Rule Waivers

  • No, our ACO does not use the SNF 3-Day Rule Waiver.
Arrangements Disclosed
The ACO Board of Managers for Caravan Health ACO 14 LLC (“Board”) has formally determined the following arrangements are reasonably related to the purposes of the Medicare Shared Savings Program (“MSSP”), as required for use of the MSSP ACO Participation Waiver:
Participant Support Arrangements
Under the applicable Participant Agreements between the ACO and the Participants listed above, certain Participants are designated as Principal Participants and others are Non-Principal Participants.  Under the Service Agreements between each Participant and Caravan Health, Inc., the Principal Participants have agreed to pay for certain ACO-related expenses of the Non-Principal Participants in their respective regions, including management fees owed by each Non-Principal Participant.  In each case, the fees and other expenses paid by the Principal Participants on behalf of the Non-Principal Participants will be set in advance, will not vary based on the volume or value of any referrals between the Principal Participants and Non-Principal Participants (except to the extent such referrals indirectly contribute to the earning of shared savings or shared losses as applicable).
Through a formal resolution dated March 27, 2018, the Board determined that these arrangements are reasonably related to the purposes of the Medicare Shared Savings Program because they facilitate the participation of the Non-Principal Participants in the Medicare Shared Savings Program, which: i) promotes the accountability of Non-Principal Participants for the quality, cost, and overall care for a Medicare patient population as described in the Shared Savings Program; ii) promotes the management and coordination of care for Medicare fee-for-service beneficiaries attributed to Non-Principal Participants through an ACO; and iii) encourages investment in infrastructure and redesigned care processes for high quality and efficient service delivery for patients, including Medicare beneficiaries, served by Non-Principal Participants.
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