Mark Angelo, MD, MHA, FACP
Interim CEO and President
Delaware Valley Accountable Care Organization

From the Interim President & CEO


Serious Illness Initiative and Addressing Social Needs
November 2021

DVACO is moving forward with a strategy to identify and manage two key populations: those with serious illness and those with social needs that are impacting their health status (also known as social determinants of health.)

Serious Illness Initiative
The serious illness initiative identifies those individuals with chronic illness and acute care utilization who may benefit from care coordination. Appropriate documentation of chronic illnesses is essential to success in this program. Serious illness is determined from documentation of at least one illness on the list of serious illnesses (i.e.- cancer, organ failure, dementia) plus at least one hospitalization. Patients receiving care from multiple providers are noted at risk for fragmented care. The program flags patients in Bamboo Health (formerly known as Patient Ping) and in the DVACO Northstar® tool, a proprietary analytics platform, available to providers in participating practices.

Addressing Social Needs
In the social needs program, our guiding and overarching goal is to improve health equity and access across the DVACO community. DVACO identifies individuals in a particular geography with social needs adversely impacting their health. We utilize U.S. census data combined with additional survey information to uncover a particular “census tract.” This may be a neighborhood or even a couple city blocks. For populations residing in these areas, we have information on employment status, education, substance use, safety, food and transportation access, etc. Through community organization partnerships, DVACO activates resources to help mitigate these barriers to health in our most vulnerable patients.

As always, we rely on and are appreciative of the support of the physicians who partner with us to positively impact the health of our community.


Wins and Challenges
January 2019

Among many activities of the DVACO in 2020, I highlight the following:

  • Jefferson Health, Main Line Health, and DVACO’s collaborative post-acute care strategy was recognized for the third year in a row with a major award for its Innovation by winning HAP’s 2020 Living the Vision Achievement Award.
  • Increased our ability to profile specialists by adding an oncology view into cost and utilization. This data, a complement to our cardiology profiling, continues to mature now and will be used to better understand and promote standardization in oncology care.
  • We have moved all care coordination on to the EPIC platform to improve communication with providers and facilitate longitudinal care for our patients.
  • Working in a remote model, DVACO facilitated resources for network independent providers during the COVID first and now second waves. These resources include telehealth, CMS funding, regional grants, PPE, private payer opportunities, etc.
  • Our analytics and operations teams pivoted to bring the new Power BI platform to fruition. This product creates a user-friendly interface that allows for providers and practice leaders to view performance in many aspects, to compare their performance to that of their peers, and to understand better what activities are needed to perform successfully in quality reporting.
  • Further advanced collaboration among DVACO, Main Line Health, and Jefferson to ensure the essential sharing of best practices and programs across both networks.

This year, DVACO will continue our march forward into successful value-based care engagements with higher levels of risk and reward.

Some of the challenges we will face include:

  • Adjusting to a post-COVID world where quality performance may be difficult to assess
  • Assisting practices with their recovery and embedding permanent telehealth and home-based resources for the network
  • Creating new workflows as we refocus our efforts on those patients with the highest need in the community
  • Meeting a myriad of new CMS regulations both known and yet to be announced

Together we will continue to strive toward our mission of improved care of our communities through quality initiatives and mindful resource utilization.