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ChristianaCare Reduces Health Care Costs by $6.2 Million While Improving Care for Medicaid Patients

Proven care management model delivers cost savings and quality improvement to state while addressing health inequities

Jan 23, 2025

3 min

Rose Kakoza, M.D., MPH

ChristianaCare’s Delaware Medicaid Partners Accountable Care Organization (ACO) has set the standard for innovative, high-quality care at lower cost for the State of Delaware’s Medicaid population. According to the most recent data available, ChristianaCare’s ACO reduced health care spending by $6.2 million in 2023 while improving care for nearly 30,000 Medicaid beneficiaries in Delaware, including approximately 8,000 children.


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“We’re demonstrating that population health works,” said Christine Donohue-Henry, M.D., MBA, chief population health officer, ChristianaCare. “Our neighbors count on us to take care of them — and we can improve their health while also helping the state reduce health care costs. We do this by delivering high-quality care that emphasizes preventive care and proactive management of health conditions, and by investing in our population health infrastructure.


“In this way, we can keep people healthier and reduce the need for them to access the most expensive kinds of care, such as emergency care and hospitalization.”


ChristianaCare’s Medicaid ACO includes more than 1,900 primary and specialty care clinicians who partner with patients and families to prevent illness, manage chronic diseases and help them achieve their health goals. The ACO makes it easy for adults and children to get the screenings and treatments they need, improving overall health.


ChristianaCare’s Medicaid ACO is one of four authorized by the State of Delaware and the only one to voluntarily accept downside financial risk at its launch in 2021, which means that if ChristianaCare’s Medicaid ACO is not successful in reducing cost and improving care for a particular year, the ChristianaCare ACO is required to make a payment to the state. By sharing in both savings and losses, the ACO controls state health care costs while maintaining high-quality care.


Bending the Cost Curve by Focusing on High-Quality Preventive Care

Alongside financial savings, ChristianaCare’s Medicaid ACO has improved care quality and worked to reduce health disparities. By focusing on preventive care, the ACO has helped adults and children get the screenings and treatment they need, leading to better health outcomes and fewer unmet needs.


Since launching in 2021, ChristianaCare’s ACO has met all required quality standards and consistently improved its performance each year on key measures like diabetes management, blood pressure control and breast cancer prevention. Year over year, breast cancer screenings have increased by 4%, while patients with high blood pressure (hypertension) have shown improvement in blood pressure control. Notably, healthy blood sugar levels (HbA1c less than 8%) have also improved in patients with diabetes by 7%.


In collaboration with its Medicaid health plan partners, ChristianaCare primary care and imaging teams host patient-centered health and wellness day events to increase access to care, close quality gaps and improve the overall health of the communities they serve. These events help patients get preventive screenings and services, supporting the ACO’s goals of better care and health equity.


The ACO’s success is driven by its focus on caring for entire families, including addressing the needs of pregnant mothers and supporting children and adults throughout their lives, according to Rose Kakoza, M.D., MPH, senior clinical network director, ChristianaCare Clinical Alliance.


Key programs include enhanced maternity care to support mothers and infants, expanded mental health services and social support programs that address food and housing needs. By integrating clinical care with social support — such as help with food and housing — the ACO is working to break cycles of poor health across generations. This approach also has practical benefits. For example, the improved mental health of a parent strengthens the family environment, supporting children’s well-being and development.


“By making significant investments in population health and addressing both medical needs and the social drivers of health, we’ve not only improved health outcomes but also more effectively managed costs for Delaware’s most vulnerable residents, helping to reduce state spending,” Kakoza said.


About Delaware Medicaid Partners

Delaware Medicaid Partners ACO, led by ChristianaCare, uses a family-centered approach to save money and improve care for Medicaid patients. By combining medical care with social support, the ACO addresses the unique needs of Medicaid patients, improving health and promoting equity. Care coordination is provided by ChristianaCare’s CareVio®, whose team of nurses, social workers, and pharmacists help patients with serious health conditions get the care they need. CareVio uses real-time data to prevent complications that could lead to unnecessary hospital stays or emergency visits. Through ongoing collaboration and innovation, Delaware Medicaid Partners ACO aims to set an example for other states working to improve care while managing costs.

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Rose Kakoza, M.D., MPH

Rose Kakoza, M.D., MPH

Senior Clinical Network Director, Population Health

Dr. Rose Kakoza specializes in using primary care to improve health equity and the effectiveness of accountable care.

Primary CarePrimary Care Delivery ReformPopulation HealthHigh Risk Population Management

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4 min

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2 min

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