Cascadia Community Care Alliance

Benefits For Patients

Cascadia CCA helps patients get the right care, in the right place and at the right time. Seeing doctors, or other caregivers that are part of the program means you have more support. This may include:

  • Working with a care manager who tracks your visits, recommends next steps and removes barriers such as missing referrals or forms.
  • Getting home health services even if you’re not fully homebound.
  • Going to a nursing home without first having a three-night hospital stay.
  • Getting priority scheduling for in-person visits.
  • Seeing a mental health doctor or other caregiver at the same clinic where you get primary care.
  • Joining PeaceHealth’s Flourish program without a fee. Flourish helps you manage chronic health conditions. Cascadia CCA covers the cost for you.

Sign up online at Medicare.gov for additional no-cost health care services, or call 1-800-MEDICARE (1-800-633-4227).

Already a Cascadia CCA member? Call us at 1-833-838-6307 to learn about making the most of your benefits.

Community Resources

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Supporting Your Care Journey

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To bridge gaps in care, several doctor or other caregiver groups have come together to form an accountable care organization (ACO). This new entity is called Cascadia Community Care Alliance. Working with Medicare, it offers coordinated care and improved benefits for people who qualify.

Cascadia CCA includes PeaceHealth Medical Group, independent community doctors or other caregivers, skilled nursing homes and home health agencies. Our goal is to help participants stay healthy and smoothly transition between home and the hospital when necessary. We also offer care navigation, support services and access to home health care when patients need it.

What is Cascadia Community Care Alliance (Cascadia CCA)?

Cascadia CCA is a group of healthcare doctors or other care teams working together to make Medicare serve you better. Its members include PeaceHealth Medical Group, community doctors or other caregivers, nursing homes and home health agencies.

You may hear the program called an “accountable care organization” (ACO). Cascadia CCA also may be called a “direct contracting entity” (DCE). This is one type of ACO.

Cascadia CCA is part of a program with Medicare called ACO REACH. Its patients get more coordinated care and personal attention. They also may qualify for fewer fees on some services and easier access to others.

What is ACO REACH?

ACO REACH stands for Accountable Care Organization Realizing Equity, Access and Community Health.

It is a way of providing Medicare services that gives patients better access to highquality care. Its goal is to make it easier for people to get — and stay — healthy. This includes people who have been underserved in the past.

ACO REACH launched on Jan. 1, 2023. It replaced a program called the Global and Professional Direct Contracting (GPDC) Model.

What is an Accountable Care Organization (ACO)?

An ACO is a group of doctors, hospitals and other caregivers that work together to offer better care for patients. Our ACO includes PeaceHealth Medical Group, community doctors or other care teams, nursing homes and home health agencies.

Does Cascadia CCA limit where I can get health care?

No. Your Medicare benefits do not change. You still have the right to see any doctor, hospital or other caregivers that takes Medicare.

Does Cascadia CCA cost more for patients?

No. Patients who qualify get added services at no extra cost.

Since your doctors or other caregivers work closely with each other, you also can avoid repeated tests or visits that you don’t need. This may save you time and money.

How do I join Cascadia CCA?

You may already be signed up. Medicare enrolls most patients based on past claims.

You can also join by contacting Medicare.

Call 1-800-MEDICARE (1-800-633-4227) or go to medicare.gov to sign up. You'll be asked to provide the name of your main healthcare doctor or other caregiver. This helps Medicare see if Cascadia CCA is right for you.

How will I know I'm signed up?

All patients get a notification letter once a year.

If you contact Medicare to sign up, you will get a letter within three months. It will be mailed once a year after that.

How can I learn more?

If you got a notification letter and have questions, call us at 1-833-838-6307. We can explain how to make the most of your benefits.

If you are not yet signed up, reach out to Medicare. Call 1-800-MEDICARE (1-800-633-4227) or go to medicare.gov to get started. 

It's important to know that all patients have the freedom to choose to take part in this or any ACO.

Frequently Asked Questions


Participating Entities

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For Community Doctors, or other Caregivers and Practice Managers

Documentation:

For more information, call 1-833-838-6307, or contact the PeaceHealth System Director, Value Based Care Programs, Daleasha Hall.

Public Reporting

Plan Year 2023 Performance
Quality Measures Performance 
 

Medicare tracks quality by looking at hospital readmissions, unplanned admissions, and timely follow-up after flare-ups of chronic conditions. In the third performance year we achieved the following results:  

Total quality score: 97.3%

  • ACR score = 14.21 – Ranked 5th out of 132 ACO REACH programs
    • ACR: Risk-Standardized, All-Condition Readmission. A lower (↓) score indicates better performance.
  • UAMCC score = 30.30
    • UAMCC: Risk-Standardized, All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions. A lower (↓) score indicates better performance.
  • TFU score = 68.69
    • TFU: Timely Follow-Up After Acute Exacerbations of Chronic Conditions. A higher (↑) score indicates better performance.

These high-quality results helped us achieve additional recognition for sustained exceptional performance. We ranked in the top 25% of the high-performers pool for this ACO REACH program.

Shared Savings Information 
 One of the goals of the ACO REACH program is to enhance care for patients while reducing costs. With our help, Medicare saved just over 8 million dollars (compared to expected spending) in calendar year 2023 for our Cascadia CCA patients. As shown above, this was done while maintaining and, in some cases, increasing the quality of care. Medicare rewards good work like this by sharing about half the savings. We received a net total of $3,980,011. We are investing 38% of that amount into care infrastructure, redesigning care processes and other resources. This will help us continue to enhance quality, improve outcomes and further reduce Medicare costs for beneficiaries. Our participating doctor or other caregiver groups received a portion of the remaining 62%, according to the Cascadia CCA Shared Savings Distribution Policy.
Plan Year 2022 Performance
Quality Measures Performance 
 

Medicare tracks quality by looking at hospital readmissions, unplanned admissions, and timely follow-up after flare-ups of chronic conditions. In the second performance year we achieved the following results: 

  • ACR score = 13.97 – Ranked 3rd out of 99 ACO REACH programs
  • UAMCC score = 30.80 – In the top third of all ACO REACH programs 

ACR: Risk-Standardized, All-Condition Readmission
UAMCC: Risk-Standardized, All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions

Shared Savings Information 
 One of the goals of the ACO REACH program is to enhance care for patients while reducing costs. With our help, Medicare saved almost 14 million dollars (compared to expected spending) in calendar year 2022 for our Cascadia CCA patients. This put Cascadia CCA in the top 30% of ACO REACH programs (when measured by cost per patient). As shown above, this was done while maintaining and, in some cases, increasing the quality of care. Medicare rewards good work like this by sharing about half the savings. We received a net total of $6,847,344. We are investing 36% of that amount into care infrastructure, redesigning care processes and other resources. This will help us continue to enhance quality, improve outcomes and further reduce Medicare costs for beneficiaries. Our participating doctor or other caregiver groups received a portion of the remaining 64%, according to the Cascadia CCA Shared Savings Distribution Policy.
Plan Year 2021 Performance
Quality Measures Performance 
 

Medicare measures participating organizations on their performance in hospital readmissions and unplanned admissions. In the first performance year, we achieved the following results:

  • ACR score = 13.59
    • Almost 10% better than average
  • UAMCC score = 29.82
    • Better than average

ACR: Risk-Standardized, All-Condition Readmission
UAMCC: Risk-Standardized, All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions

Shared Savings Information 
 
  • Net shared savings = $1,961,081 for calendar year 2021
  • Invested 50% into
    • Care Infrastructure
    • Redesigning care processes
    • Other resources necessary to improve outcomes and reduce Medicare costs for Beneficiaries
  • The remaining 50% was distributed to our participating doctor or other caregiver groups according to the Cascadia CCA Shared Savings Distribution Policy

Senior Leadership

  • Melissa Edwards, MD - Chief Executive – Cascadia Community Care Alliance
  • Daleasha Hall, MDiv, MBA – System Director – Cascadia Community Care Alliance
  • Simon Lai, MD – Chief Medical Officer – Cascadia Community Care Alliance

Governing Board Members

  • Binod Dhungana, MD – PeaceHealth Medical Group
  • Mike Dwyer (Chair) – PeaceHealth
  • Melissa Edwards, MD - PeaceHealth Medical Group
  • Jeff Frank, MD – Oregon Neurology Associates
  • Erin Gerner - PeaceHealth Medical Group
  • Bruce Hostetter - Medicare Consumer Advocate
  • Garrett Jeffery, DO – PeaceHealth Medical Group
  • Simon Lai, MD - PeaceHealth Medical Group
  • Participating doctor or other caregiver – OPEN
  • Leon McCook, MD - PeaceHealth Medical Group
  • Natasha O’Neal, MD – PeaceHealth Medical Group
  • Shelley Rice, MD – PeaceHealth Medical Group
  • James Sims, NP - PeaceHealth Medical Group
  • Susan Vaughan – Medicare Beneficiary
  • Ashok Venkataraman, MD – PeaceHealth Medical Group
  • Catherine York, MD – Women’s Care