1. The Rhode Island Care Transformation Collaborative A Progress Report : Quality, Patient Experience and Service Utilization March, 2016

2. Table of Contents 2 Topic Pages Background3-4 Executive Summary5 Quality6 - 15 Nurse Care Manager16 - 17 Patient Experience18 - 23 Service Utilization24 - 31 Conclusions32 Appendices Appendix A: List of Participating Practices Appendix B: Measure Specifications 33 – 37

3. Background The mission of the Rhode Island Care Transformation Collaborative (CTC-RI) is to lead the transformation of primary care in Rhode Island in the context of an integrated health care system; and to improve the quality of care, the patient experience of care, the affordability of care, and the health of the populations it serves. Launched in 2008 by the Office of the Health Insurance Commissioner with five pilot sites, CTC currently supports 72 practice sites. CTC implemented several important initiatives in 2015 including:  The program added 8 practices, consisting of 25 sites, in January 2015  For the first time, CTC reported performance metrics on nurse care manager activity for high risk patients  The CTC Advanced Collaborative, consisting of the initial 15 CTC practices, was formed. The Collaborative provides health plans and CTC-RI practices an ongoing platform for innovation and translation of theory and best practices into action 3

4. Background  The Advanced Collaborative practices, their respective organizations and key health plan representatives make up the initial membership of the CTC Clinical Strategy and Cost Committee (CSCC), which is responsible for identifying and testing clinical and financial strategies to improve quality and reduce cost  CTC launched PCMH Kids, a range of pediatrics practice sizes, geographic locations and experience with PCMH transformation. Together, they serve approximately 30,000 covered lives, 48% of which are covered through a Medicaid Managed Care plan 4

5. Executive Summary Rhode Island Care Transformation Collaborative (CTC-RI) is driving the transformation of primary care in Rhode Island by spreading effective models to deliver, pay for and sustain high quality, comprehensive, accountable primary care through the Patient-Centered Medical Home (PCMH) model. To assess the effectiveness of the PCMH model, CTC-RI measures performance of the participating primary care practices on quality, patient experience and service utilization. This report presents a qualitative review of the program results for the period Q4 2011 - Q3 2015. Key findings include:  The Transition Group seems to experience continued erratic results in the quality measures, more so than did the other groups in their earlier years. Progress for Performance Group 1 has also been a bit uneven for some measures in 2015.  After a year of training and testing, CTC reported the first results in Nurse Care Manager measures for high risk patients, a significant milestone in CTC’s strategic priority of concentrating on programs that focus on high and rising risk patients and on reducing total cost of care in areas that primary care can impact. The CTC practice cohorts reached between 36% and 56% of their high risk patients with NCM services.  Over time, there has been little change in CTC practices’ results in the CAHPS survey. Very few practices had significantly significant increases or reductions in performance from 2014 to 2015.  The CTC-RI program is out-performing the non-PCMH practices in reducing hospital admissions. Across all payers, non-PCMH comparison practices have demonstrated an overall upward trend in all-cause admission rates over the past three quarters. For the first time, both CTC cohorts saw reductions in ED Visit rates, while the comparison group rate increased. 5

6. How and Why We Measure Quality 6 Practices involved in the CTC-RI program capture clinical metrics from their practice management and electronic medical record systems. They identify patients with certain clinical conditions that require monitoring and/or who are candidates for certain medical interventions. They then determine whether the results of the monitoring reflect good management of the clinical condition or if the appropriate services have been rendered. Understanding performance on these measures helps us to assess whether the Patient Centered Medical Home intervention is impacting delivery of evidence based care. These quality measures are a proxy for the delivery of the right care at the right time in the right place for the right patient. Detailed measure specifications are included in Appendix B.

7. Quality Measures for the Period Ending September, 2015 Contract measures Adult BMI Measurement (18-64 and 65+) Diabetes A1c Good Control Diabetes Blood Pressure Control Hypertension Blood Pressure Control Tobacco Cessation Intervention Other Measures Diabetes HbA1c Poor Control Tobacco Assessment Depression Screening 7

8. Adult BMI Measurement 8 Results and Significance All performance groups have demonstrated improvement in the Body Mass Index (BMI) measure for adults from their entry point into the CTC-RI program. For the 2015-2016 year, targets for both of the BMI measures increased substantially; for the age group 18-64, an increase from 70% to 85% and for the age group 65+, 75% to 90%. For both BMI age ranges, in the last 3 reporting periods all Performance level groups continued to improve and the Advanced and Performance Group 2 almost achieved or achieved the new targets for the last 3 quarters. Performance Group 1 continues to improve in the age 18-64 measure but has 13% points to go to attain target. The Transition group dropped 20 points from Q1 to Q3 in the 18-64 measure, while in the 65+ measure, it dropped 6 points in Q2, but increased performance in Q3 for a net gain of 6 points. The Startup Group has predictably low results for its first 2 reporting periods. These results suggest that, despite some erratic performance in the Transition Group, practices involved in CTC-RI have shown improvement in the BMI measure for adults over the reporting time period, so much so that the target was increased.

9. Diabetes A1c Good Control 9 Results and Significance In Q3, none of the performance groups achieved the target in A1c Good Control. With the exception of Performance Group 2, all performance group practices had a decline in good control between Q1 and Q2 of 2015. Two of the three declining performance groups showed some improvement in Q3 2015, but none of the declining groups returned to Q1 2015 performance. The Startup Group saw a good increase between Q2 and Q3. These results suggest that practices involved in CTC-RI may be having challenges in holding the early gains made in this diabetes outcome measure. However, many of the CTC sites were in the process of converting from one EHR to another during 2015, which may be one cause for the disruption in measurement practices. Definition and Importance A1c refers to glycosylated hemoglobin, the part of the red blood cell which carries glucose, or blood sugar. It is monitored in patients with diabetes to determine how well the individuals blood sugar levels have been controlled over the past 3 months. This measure looks at the percentage of diabetic patients (Type 1 or 2) age 18-75 with controlled blood sugar, having an A1c value less than 8.0%.

10. Diabetes Blood Pressure Control 10 Results and Significance The Advanced Group was the only group to achieve target in Q3. Performance Group 2 just missed target and results for Performance Group 1 declined over the last few quarters. Except for Performance Group 2, which had a slight dip, all groups had positive results in Q3. In every reporting period of 2014, Performance Groups 2 and Advanced were at or near target. The Transition Group is on the upswing after a decline in Q2. The Startup Group had good results in the last two quarters. These results suggest that practices involved in CTC-RI have shown marginal improvement in the Diabetes Blood Pressure Control measure over the entire reporting period. Like HbA1c, maintaining high performance on this measure is dependent on a variety of factors, including patient adherence to treatment plan. Definition and Importance Blood pressure readings measure the force on the walls of the arteries as the heart pumps blood through the body. Elevated blood pressure readings are associated with higher risk of heart attack or stroke. Patients with diabetes have even greater risk of heart attack or stroke, so blood pressure in these patients should be carefully managed. This measure looks at the percentage of diabetic patients (Type 1 or 2) age 18-75 who had a blood pressure value less than 140/90.

11. Hypertension Blood Pressure Control 11 Results and Significance During the most recent quarter (Q3 2015), the Advanced Group was the only group to achieve target in Hypertension Control; the Transition and Performance 2 Groups were within 1.5 percentage points away from achieving the target. Performance Group 1 has declined in performance since Q3 of 2014 and is now 16 points under target. The target for this measure increased 4 points from 76% to 80% in 2015-2016, which is a significant increase for a control measure. These results suggest that over time, most of the CTC sites have kept up with a gradually increasing target. Unlike other measures, the Transition Group’s scores align with the Advanced and Performance 2 Groups and Performance Group 1’s score has been consistently lower. Definition and Importance Blood pressure readings measure the force on the walls of the arteries as the heart pumps blood through the body. Elevated blood pressure readings are associated with higher risk of heart attack or stroke. Patients with diabetes have even greater risk of heart attack or stroke, so blood pressure in these patients should be carefully managed. This measure looks at the percentage of patients age 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled during the measurement year, having a BP value of <140/90.

12. Tobacco Cessation Intervention 12 Results and Significance All of the performance groups have improved or maintained target for the past 5 periods, with the exception of a dip in Performance Group 1’s results in Q1 2015. The Transition Group has made substantial progress in every quarter since Q1 2014, but leveled off in Q3 2015. The Tobacco Cessation Intervention measure is a process measure and expectations are high, with a target of 90%. These results suggest that practices involved in CTC-RI who have been program members the longest have the higher and most consistent results. Definition and Importance Tobacco use is the leading cause of preventable death in the United States. Smoking injures nearly every organ in the body. The advice of members of the primary care team have a significant impact on quit rates. This measure looks at the percentage of tobacco users in the total active patient population, given tobacco cessation advice including one or more of the following: advice to quit, counseling, referral for counseling, and/or pharmacologic therapy during the measurement period.

13. Diabetes A1c Poor Control 13 Results and Significance The Advanced and Performance Groups 1 and 2 have had steady performance in this measure since 2013. No longer a contract measure, HbA1c Poor Control does not have a target. However, the Advanced and Performance 1 Groups have maintained the previous target (~21%) for many quarters. The Transition practices have not shown significant improvement since the beginning of 2014. Though just beginning in the CTC program, the Startup Group has attained the previous target of 21% in Q3. Because the HbA1c Poor Control measure looks at the number of patients who are not in control, a lower score is better These results suggest that practices involved in CTC-RI have gradually improved over time in HbA1c control and continue to move in the right direction. Again, variability in results is typical for practices new to measurement. Definition and Importance A1c refers to glycosylated hemoglobin, the part of the red blood cell which carries glucose, or blood sugar. It is monitored in patients with diabetes to determine how well the individuals blood sugar levels have been controlled over 6-8 weeks. Poor control is associated with a significant increase in diabetes related complications. This measure looks at the percentage of diabetic patients (Type 1 or 2) age 18-75 with poorly controlled blood sugar, having an A1c value greater than 9.0%. A lower score is better.

14. Tobacco Assessment 14 Results and Significance Tobacco Assessment measure results have improved for all Performance level groups, with exception of the Transition Group, which has demonstrated significant swings in performance over the past several quarters. The more established groups have reached and maintained very high scores in this measure. Tobacco Assessment is a process measure and expectations are high. These results suggest that once practice workflow is established, most providers score high in this measure. Often times, lower scores in this, and other process measures, may be due to changes in practice workflow or EHR systems. Scores for the groups newer to CTC are typically more erratic as the practices are defining and refining workflow. Definition and Importance Tobacco use is the leading cause of preventable death in the United States. Smoking injures nearly every organ in the body. The advice of members of the primary care team have a significant impact on quit rates. This measure looks at the percentage of patients age 18 and older who were questioned one or more times about tobacco use during the measurement period.

15. Depression Screening 15 Results and Significance With the exception of the Startup Group, all performance groups have improved or maintained high performance on the Depression Screening measure over the past five quarters. The Transition Group has had very erratic results but its score has been rising substantially since its lowest score in Q1 2014. Though no longer a contract measure, CTC’s expectation is that practices perform well in this important measure. CTC is interested in adopting more behavioral health focused measures and has recently been awarded a grant to pilot Anxiety and Substance Abuse Screening for a small group of CTC practices, in addition to the Depression Screening measure. These results suggest that practices involved in CTC-RI have performed well over time. With the exception of the Startup and Transition Groups, performance groups with the best baseline performance demonstrated the least overall change. The variability with the Startup and Transition Groups is likely related to measurement practices or stability. Definition and Importance Depression is the second most common medical problem diagnosed and treated in the primary care setting. Depression is associated with the same degree of disability as other chronic conditions such as diabetes, and it a highly amenable to early treatment. This measure looks at the percentage of patients age 18 and older screened one or more times for depression during the measurement period, using a standardized screening tool (PHQ-2 or other validated tool)

16. How and Why We Measure Nurse Care Manager Activity 16 One of CTC’s strategic priorities is to reduce cost through focus on high risk patients and improved health plan communication and coordination. Last year CTC identified three categories of high cost patients and developed measures and metrics to calculate nurse care manager activity with those patients. The categories of patients are: High Cost/High Utilizer – Patients with 3 or more ER visits or inpatient admissions in 6 months Complex/Poorly Controlled – Patients with 3 or more chronic conditions Health Plan Identified – Patients referred by health plans as high risk The two measures are High Risk Patients with Nurse Care Activity Non High Risk Patients with Nurse Care Manager Activity In Q3 2015, CTC practices began reporting results for these measures.

17. High Risk and Non High Risk Patients with Nurse Care Activity 17 Results and Significance Results include Q3 2015 metrics. In this first reporting period, the Transition Group had the highest performance in the Nurse Care Manager Activity with High Risk Patients, followed by the Advanced, Performance Group 1 and Performance Group 2. In the Non High Risk measure, there was little variation in the results, with Performance Groups 1 and 2 at 8% and Advanced and Transition at 6%. It’s much too early to make any assessment of these results. For the first reporting periods, practices are learning how to capture and calculate the data according to the measure specifications. The Practice Reporting Workgroup, where practice data analysts collaborate on techniques, best practices and overcoming obstacles in measure calculation, will add Nurse Care Manager measures to its monthly agenda. Definition and Importance Nurse Care Managers play a crucial role in health outcomes of high risk patients. To assess the amount of time NCM spend with these patients, CTC established three categories of high risk patients and developed these measures Percentage of high risk patients who had any Nurse Care Manager activity during the last 6 months Percentage of non-high risk patients who had any Nurse Care Manager activity during the last 6 months (total patient panel minus high risk patients)

18. How and Why We Measure Patient Experience 18 Patient Experience is measured with an annual survey which employs questions that have been validated by researchers to ensure that they are accurately measuring the topic of interest. Patients seen in the PCMH practice in the past year are randomly sampled to receive a paper survey in the mail, followed by up to 5 phone calls made by an independent surveying organization. The questions are then aggregated into topic specific composite scores (e.g., Access). Understanding how patients perceive the care they receive is necessary to implement interventions that will promote patient engagement. Detailed measure specifications are included in Appendix B.

19. Patient Experience Measures for the Period Ending Spring 2015 Access Communication Office Staff Comprehensiveness (Adult Behavior) Self Management Support Shared Decision Making 19

20. Patient Experience: CTC Performance Compared to National Benchmarks Definition and Importance This graph looks at CTC 25 th, 50 th and 75 th percentile s compared with the National CAHPS Benchmarking Database median in all domains. The purple column represents the CTC top score. 20 Results and Significance The CTC median performance compared favorably to the national median scores on all composite metrics with the exception of Office Staff, where the CTC 75 th percentile was virtually equivalent to the national 50 th percentile. The CTC median was considerably higher than the national median on the Adult Behavioral domain, which reflects the availability of comprehensive care. CTC practice scores show low variability on the Communication, Shared Decision Making and Patient Self Management domains; whereas, the Access, Adult Behavioral and Office Staff domains have a large difference between those practices in the 25 th percentile vs. the highest performing practices. These results suggest that CTC is generally performing well on CAHPS Patient Experience Survey and exceeds the national score in the domains that focus on providers’ ability to encourage patients to engage in their own care and in coverage of behavioral health in health care discussions. Office Staff is an ongoing opportunity for the CTC practices. The regional results show similar patterns.

21. Patient Experience: Cohort Comparison Results and Significance Performance Group 1 out performed the other cohorts in 4 of 6 domains. This cohort, which joined CTC in 2013, has consistently shown strong performance in CTC metrics. Performance Group 3, which has been in the CTC program the longest, was the top performer in just one of the 6 domains. 21 Definition and Importance This graph compares the 2015 scores for the Performance cohorts and displays the current CTC median.

22. Patient Experience: Year over Year Change Results and Significance As a group, CTC practices did not demonstrate statistically significant improvement in performance between 2014 and 2015. Access was one domain where both positive and negative year over year differences were seen; that was likely due to a single question which was included in the Access composite despite small sample sizes. (See page 23) These results may suggest that the quality improvement initiatives that practices have implemented thus far have been ineffective in improving these the patient experience of care in a meaningful way. 22 Definition and Importance This graph looks at the number of practices whose performance was statistically significantly higher or lower scores in 2015 relative to 2014.

23. Survey Results – Contract Measures Patient Experience: Access Composite Challenge 5 Contractual Performance Standards Each question in a composite is weighted equally regardless of sample size Question 16* had low sample size for many RIQI analyzed results with and without #16 CTC removed #16 from the composite in the PCMH 2.0 survey currently in the field for 2016 contract adjudication PCMH 3.0 Access composite excludes #16 *I n the last 12 months, when you phoned this provider’s office after regular office hours, how often did you get an answer to your medical question as soon as you needed? 23

24. How and Why We Measure Service Utilization Service utilization is measured using paid health insurance claims, which reflect lag in reporting relative to the quality measures which are extracted from practice medical records quarterly. We assess the number of services a group of patients with a specific type of health insurance have had over a specified time period. Understanding how often patients are hospitalized or visit the emergency room and for what types of conditions helps us to assess whether the Patient Centered Medical Home intervention is impacting utilization patterns in the most expensive care settings, the hospital. These utilization measures are a proxy for healthcare spending in these settings. Data was available for patients associated with practices in the Advanced Collaborative and Performance Group 1. Performance Year 1 is identified in these analyses as Cohort 2 and represented as a red line. The Advanced Collaborative is identified in these analyses as Cohort 1 and they are represented by a blue line. A description of the participating practices is included in Appendix A. The comparison group is comprised of patients in practices not engaged in a Patient Centered Medical Home project and is represented by a green line. Detailed measure specifications are included in Appendix B. 24

25. Service Utilization Measures for the Period Ending December, 2014 Contract measures All Cause Admission Rate All Cause ED Visit Rate Additional Measures Ambulatory Care Sensitive Admission Rate Preventable ED Visit Rate 30-Day All Cause Readmission Rate Observation Stay Rate 25

26. All Cause Inpatient Admissions Rate per 1,000 Definition and Importance Health care service utilization and associated costs account for a large portion of the U.S. economy, and health care cost growth has outpaced inflation for decades. Understanding the drivers of cost, including hospital admissions is essential to determining the effectiveness of the PCMH intervention. The All-Cause Admission rate reports on the number of hospital admissions per 1,000 member months, excluding any admissions for pregnancy, mental health, or chemical dependency services in adults ages 18 years and older. Results and Significance Though the change over time and the difference in the cohorts’ performance are small, across all payers, non-PCMH comparison practices have demonstrated an overall upward trend in all-cause admission rates over the past three quarters while CTC practices have declined or evened off. For period beginning in September, 2013 through December 2014, CTC-RI Cohort 1 has improved its performance in overall hospital admissions from 8.65 to 8.11 admissions per 1,000 member months. Cohort 2 also declined from December of 2013 though June of 2014 and has leveled off at 9.44 admissions per 1000 member months. The comparison group, on the other hand, has seen increases in hospital admissions from June through the end of 2014, with a closing rate of 10.82 admissions per 1000 member months. These results suggest the CTC-RI program is out-performing the non-PCMH practices in reducing hospital admissions. 26

27. Emergency Department Visits Rate per 1,000 Results and Significance In Q2 2014, for the first time in contract adjudication, both CTC cohorts had reductions in ED visit rates, while the comparison group saw increases. Though the decrease was not significant enough for incentive payment, it represented what is hoped to be a positive turn for CTC in reducing its ED visit rate. Cohort 2 has consistently outperformed both Cohort 1 and the comparison group in this measure. The two cohorts’ results in this measure are the reverse of those for hospital admissions. Since Q2 2014, all groups have seen increases in ED Visit rates; the comparison group’s increase was larger than either of the CTC cohorts’ increases. 27 Definition and Importance Health care service utilization and associated costs account for a large portion of the U.S. economy, and health care cost growth has outpaced inflation for decades. Understanding the drivers of cost, including emergency department use, is essential to determining the effectiveness of the PCMH intervention. The All-Cause Emergency Department Visit Rate reports the number of ED visits per 1,000 member months, excluding visits that lead to admissions or observation stays and any visits for pregnancy, mental health, or chemical dependency services, in adults ages 18 years and older.

28. Ambulatory Care Sensitive Condition Admissions Rate per 1,000 Results and Significance For all payers in all groups, the rate of Ambulatory Care Sensitive Condition (ACSC) Admissions over time has been under 1 per 1,000 member months. Though the rates across RI coverage types vary, overall, ACSC Admissions is not one of the higher priority measures targeted for reduction. 28 Definition and Importance Health care service utilization and associated costs account for a large portion of the U.S. economy, and health care cost growth has outpaced inflation for decades. Understanding the drivers of cost, including hospitalizations which are sensitive to care received in the primary care setting is essential to determining the effectiveness of the PCMH intervention. The Ambulatory Care Sensitive Conditions Admission Rate reports the number of hospital admissions per 1,000 member months with a principal diagnosis included in the overall the Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators (PQI) composite of ambulatory care sensitive conditions (ACSC) in adults ages 18 years and older.

29. Potentially Preventable Emergency Department Visits Percent of ED Visits Results and Significance For all practices for all payers, potentially preventable emergency department visit rates have been rising slightly for the last 4-5 quarters. Cohort 1 has higher preventable ED rate than both Cohort 2 and the comparison group. These results suggest that overall, while tracking with comparison group, the CTC-RI program is not out-performing secular trend in reducing Preventable ED visit rates. 29 Definition and Importance Health care service utilization and associated costs account for a large portion of the U.S. economy, and health care cost growth has outpaced inflation for decades. Understanding the drivers of cost, including potentially preventable emergency department use, is essential to determining the effectiveness of the PCMH intervention. The Preventable Emergency Department Visit Rate reports the percentage of Emergency Department visits that are classified as preventable in adults ages 18 years and older using the New York University algorithm.

30. All-Cause 30 day Readmissions Percent of Admissions Results and Significance For all payers and all cohorts, in the March 2012 though December 2014 measurement period, the percentage of discharges that resulted in a 30 day readmission remained steady between 10 and 20%. There is very little change over time and very little difference in the three cohorts’ performance in this measure. 30 Definition and Importance Hospital readmissions are costly and are often avoidable with primary care follow up after a hospital discharge. Health care service utilization and associated costs account for a large portion of the U.S. economy, and health care cost growth has outpaced inflation for decades. Understanding the drivers of cost is essential to determining the effectiveness of the PCMH intervention. The 30 Day All-Cause Readmission Rate reports the percentage of acute inpatient stays that were followed by a readmission within 30 days for any reason in adults ages 18 and older.

31. Observation Stay Rate per 1,000 Results and Significance For all payers, in the measurement period March 2012 through December 2014 there are very few Observation Stays; there has been very little change over time and there is very little difference in the rates for the three cohorts. 31 Definition and Importance Health care service utilization and associated costs account for a large portion of the U.S. economy, and health care cost growth has outpaced inflation for decades. Understanding the drivers of cost, including hospital observation stays, is essential to determining the effectiveness of the PCMH intervention. The Observation Stay Rate reports the number of observation stays in rolling year per 1000 member-months.

32. Conclusions Quality Measures  Among CTC-RI practices there is a general trend toward improvement over baseline for all of the quality measures. Improvement appears to occur after a period of measure stabilization for practices new to the program. Patient Experience  Though the results show that there is room for improvement, there has been little change in CTC performance year over year in the CAHPS PCMH Adult Survey. Some practices feel that a once-yearly survey may not be as effective in improving performance as other survey tools that are brief, cover a wider range of topics and provide faster, more actionable feedback. Service Utilization  In the most recent reporting period, though the numbers are generally small, CTC practices have either improved more, declined less or matched the comparison group in all measures. These results, along with the improvement seen in ED visit rates, are encouraging.  Blue Cross & Blue Shield of RI’s recent announcement of the positive results a five-year study showed of the impact of Patient Centered Medical Home on health outcomes and cost reduction is promising. The study showed that in the final year of the study, PCMH practices were 5 percent less costly and saved $30M compared to standard primary care providers. 32

33. Appendix A: List of Participating Practices: Advanced Collaborative Practice NameYear Joined CTCPerformance Group Utilization Cohort (2014) Coastal Medical, Inc.......... – Greenville 2008Advanced1 Coastal Medical, Inc.......... – Hillside 2008Advanced1 Family Health & Sports Medicine, LLC 2008Advanced1 Thundermist CHC – Woonsocket 2008Advanced1 University Medicine - Governor Street Primary Care 2008Advanced1 Coastal Medical, Inc.......... – Narragansett 2010Advanced1 Coastal Medical, Inc.......... – Wakefield 2010Advanced1 Kristine Cuniff 2010Advanced1 Memorial Hospital Center for Primary Care 2010Advanced1 South County Hospital Family Medicine 2010Advanced1 South County Internal Medicine 2010Advanced1 Stuart Demirs 2010Advanced1 Thundermist CHC – Wakefield 2010Advanced1 Blackstone Valley Community Health Care, Inc.......... 2012Advanced1 University Family Medicine 2012Advanced1 33

34. Appendix A: List of Participating Practices: Performance Group 2 Practice NameYear Joined CTCPerformance Group Utilization Cohort (2014) Anchor Medical Associates - Lincoln 201322 Anchor Medical Associates - Providence 201322 Anchor Medical Associates - Warwick 201322 Aquidneck Medical Associates - Newport 201322 Aquidneck Medical Associates - Portsmouth 201322 Associates in Primary Care Medicine 201322 East Bay Community Action Program - East Providence 201322 Medical Associates of RI - Bristol 201322 Medical Associates of RI - EP 201322 Ocean State Medical, LLC 201322 Tri-Town Community Action Agency 201322 University Internal Medicine 201322 University Medicine - 909 North Main Street 201322 University Medicine - Barrington 201322 University Medicine - East Ave 201322 University Medicine - Plain Street 201322 University Medicine - Warwick Family Medicine 201322 WellOne Primary Medicine - Foster 201322 WellOne Primary Medicine - North Kingstown 201322 WellOne Primary Medicine - Pascoag 201322 34

35. Appendix A: List of Participating Practices Performance Group 1 and Transition Practice NameYear Joined CTCPerformance Group Utilization Cohort (2014) Comprehensive Community Action Program - Coventry 20131NA Comprehensive Community Action Program - Cranston 20131NA Comprehensive Community Action Program -Warwick 20131NA Internal Medicine Partners 20131NA Thundermist CHC - West Warwick 20131NA WoodRiver Health Services 20131NA Family Medicine at Women's Care 2013TransitionNA Nardone Medical Associates 2013TransitionNA Internal Medicine Center 2013 Transition NA Richard M Del Sesto 2013TransitionNA South County Walk-in & Primary Care 2013TransitionNA Women's Primary Care, Women's Medicine Collaborative 2013TransitionNA 35

36. Practice NameYear Joined CTCPerformance GroupCohort Affinity Physicians, LLC-Arcand Family Medicine 2015StartupNA Affinity Physicians, LLC-Brookside Family Medicine 2015StartupNA Affinity Physicians, LLC-Primary Medical Group of Warwick 2015StartupNA Barrington Family Medicine 2015StartupNA Charter Care Medical Associates 2015StartupNA Coventry Primary Care Associates 2015StartupNA John Chaffee D.O. Ltd. 2015StartupNA North Kingstown Family Practice 2015StartupNA Primary Care of Barrington 2015StartupNA Providence Community Health Centers, Inc.-Capital Hill 2015StartupNA Providence Community Health Centers, Inc.-Central 2015StartupNA Providence Community Health Centers, Inc.-Chad Brown 2015StartupNA Providence Community Health Centers, Inc.-Chafee 2015StartupNA Providence Community Health Centers, Inc.-Crossroads 2015StartupNA Providence Community Health Centers, Inc.-North Main Street 2015StartupNA Providence Community Health Centers, Inc-Olneyville 2015StartupNA Providence Community Health Centers, Inc.-Prairie Avenue 2015StartupNA Solmaz Behtash, DO 2015StartupNA South County Hospital Primary Care Family and Internal Medicine-Wakefield 2015StartupNA South County Hospital Primary Care Family and Internal Medicine-Westerly 2015StartupNA Southcoast Health System-Family Medical Middletown 2015StartupNA Southcoast Health System-Family MediCenter 2015StartupNA Southcoast Health System-Linden Tree Family Health Center 2015StartupNA Southcoast Health System-Tiverton Family Practice 2015StartupNA Wickford Family Medicine 2015StartupNA 36 Appendix A: List of Participating Practices 2015 Startup Performance Group

37. Appendix B: Measure Specifications 37 Please see attached documents entitled: 1.Clinical Quality Measure Definitions 2.Hospital and ED Utilization Measure Definitions 3. CAHPS ® Clinician & Group Surveys with PCMH Items