March 30, 2021
Dorminy Medical Center Initiates Pilot Program to Increase Depression Screenings & Improve Outcomes
Rural populations experience more adverse living circumstances than urban populations and tellingly, the prevalence of depression is slightly, but statistically significantly, higher in residents of rural areas compared to urban areas. The COVID-19 pandemic and the resulting economic recession has negatively affected many people’s mental health and created new barriers for those already suffering from mental health disorders, including depression.
Many rural providers have placed more emphasis on depression screenings in order to successfully intervene when necessary. Dorminy Medical Center (DMC) serves the rural community of Fitzgerald, Georgia and has been a participant in the Caravan Collaborative ACO since 2016. Staff and providers have been trained in value-based care methodologies which place emphasis on preventive screenings.
Population Health Nurse, Michelle Seagroves, noticed that they were only capturing quality measures for patients who had an Annual Wellness Visit (AWV) – patients who had not yet had an AWV did not have these important measures captured. As staff continued to increase their AWV performance, they decided to initiate a pilot program in one primary care practice to expand the depression screening to visits other than the AWV. 
The pilot program was implemented to determine any differentials in patient outcomes. Led by Connie Spires, they verify whether or not a PHQ-9 screen has been performed with every non-AWV Medicare visit or every three months. If there is not a preventive screen on record the patient is screened, the results are documented, and a follow up plan is recorded. Staff and providers participating in this pilot program communicate daily to ensure that patients who meet the criteria are properly screened and follow-up support is provided to patients.
The expectation is that the pilot program will be a success and staff and providers will demonstrate an improved rate of screenings and interventions when indicated. The long-term plan is to deploy this process in all six DMC primary care practices with the goal to increase measure performance and improve patient outcomes.
“Depression can have long-term, detrimental effects on a patient’s health and well-being. It can also negatively impact their family members. Our goal is to continue to increase our rates of depression screenings – if we can intervene, we will increase our quality of care and our patients will experience better outcomes.”

Michelle Seagroves, Population Health Nurse
Dorminy Medical Center
March 23, 2021
Crouse Health & FamilyCare Medical Group Maintains Continuity of Care with Telehealth

Crouse Health located in Syracuse includes multi-specialty practice Crouse Medical Practice with more than 12 locations and partners with multi-specialty practice FamilyCare Medical Group with 29 locations. Combined, they have a total of 28 PCP locations to serve an expansive patient base in Central New York. As the COVID-19 pandemic made its impact on New York, both medical communities prepared for what was likely to be a long-term public health emergency. After CMS made telehealth a viable option, the providers successfully transitioned to offering virtual care to their patients – an impressive task given the multiple locations and specialties within these two medical groups.

In what appeared on the surface to be a seamless effort, they overcame technological barriers with their EMR, staff and patients. With only uncertainty as a sure thing, the collective group of staff and providers committed to offering every possible option to their patients and made efforts to ensure those patients who wanted to use telehealth had the tools and resources to do so.

As participants in the Caravan Collaborative Pathways ACO, Crouse Medical Practice and FamilyCare Medical Group gained distinction for some of the highest rates of telehealth usage across all of Caravan. While providers battled various levels of the pandemic in their communities, they recognized the potential in virtual care in an otherwise shutdown world and quickly and effectively embraced the opportunity.

Despite being embroiled in the pandemic, this group of providers continued to perform their Annual Wellness Visits (AWV), using telehealth. The virtual care implementation was so successful that their rates of AWVs were higher than their original, pre-pandemic goal. Their rates of Advance Care Planning, which is an initiative they prioritize as part of their wellness exams, also exceeded their pre-pandemic goal, increasing more than 10% from the beginning of 2020 through the third quarter. The group’s Chronic Care Management program also flourished as a result of their emphasis on virtual care. To date, data has demonstrated an improvement in enrollment rates of more than 2% during the pandemic.

The COVID-19 pandemic has disrupted health care delivery as we once knew it. Yet for Crouse Health and FamilyCare Medical Group -when offered the opportunity to transition to virtual care – they embraced new technology and effectively maintained continuity of care.

“We understand that the Annual Wellness Visit is the foundation for improving our quality of care. When we were first hit by the pandemic and telehealth became a more viable option, we didn’t look back. We adapted to virtual care and expanded our chronic care management program, because we knew it was best for our patients and best for our continuity of care.”
Seth Kronenberg, MD
Chief Operating Officer/Chief Medical Officer
Crouse Health
March 16, 2021
Fisher Titus Medical Center Reports 88% of Patients Have Completed Colorectal Screenings

Prior to Dec. 2018, Larry, a 73-year old patient had never had a colonoscopy screening. During his annual wellness visit, his population health nurse discussed the importance of the screening. He denied concerns of his family history with colon cancer but reviewed the risk factors as well as common misconceptions about the screening with his nurse. Larry was resistant to having the screening but agreed to completing a Cologuard Kit. He agreed that if the test was negative, he would repeat it again in three years but if the test was positive, he would consider the colonoscopy. Much to Larry’s surprise, the test was positive, “I was really surprised; I was not having any problems.” He agreed to have the colonoscopy which resulted in the removal of 10 polyps, including four tubular adenomas and one tubulovillous adenoma.
Larry’s experience is typical of patients who aren’t concerned with or educated to the importance of preventive screenings. Population health methodologies are founded in preventive care that lead to early detection. Larry expressed his appreciation to the nursing staff for taking the time to demonstrate how to complete the Cologuard testing. Their willingness to explain the steps and answer his questions helped to encourage him to complete a screening that ultimately led to early detection.
Since 2016, Fisher Titus Medical Center (Fisher Titus) has participated in the Caravan Collaborative Pathways ACO. When data demonstrated that Fisher Titus was not meeting the measures for recommended colonoscopy screenings, they began to emphasize the importance of the screenings. One of the biggest challenges was overcoming patient resistance. They expressed concern about the prep, the bad-tasting liquid they were required to drink and a painful procedure. 
Trayce Hanlon, LPN, the Population Health Facilitator at Fisher Titus could relate to her patient’s concerns. She was overdue for her first colonoscopy screening and decided to use this a catalyst to not only complete her personal screening but to also be able to describe, first-hand, the prep and procedure to her patients. She learned that not all prep kits were the same – some had tastier drinks than others. She also began offering Cologuard kits and provided additional information and visual education aids to help her patients better understand the procedure.
To her delight, the patients have responded well. Providers have noted the increase in the numbers of patients completing the screenings. At mid-year, 2020, during the pandemic, Fisher Titus reported that 88% of their attributed patients had completed their colorectal screenings.”
“Having additional educational pieces available that can either be reviewed with your patients during their office visit or on display in your waiting room helps them to better understand. Our patients have responded well when we’ve taken the time to review and discuss the available options.”
Trayce Hanlon
Population Health Facilitator
Fisher Titus Medical Center

March 9, 2021
Bingham Memorial Hospital Successfully Reduces Controlled Prescription Use by 50%

One of the single most difficult challenges for prescribers is to distinguish between the legitimate use of controlled substances versus overuse or reliance on the medication which can lead to hindering, rather than helping address the core problem. After reviewing patient prescription monitoring data, Dr. Brian Carrigan at Bingham Memorial Hospital (BMH), in Blackfoot, Idaho was concerned when he saw that his patient’s usage of sedatives exceeded their state average. BMH has participated in Caravan’s Health Collaborative ACO since 2019 and has embraced the team-based approach of population health. 

Together, the BMH staff began to identify patients through chart reviews and monthly prescription refills to implement a pharmacy management program. Using a team-based care approach, Melissa Mercado, RN, confirmed prescription usage in the identified patients and explained that they needed to have an appointment to discuss the continued use of the medication. Each patient was scheduled to meet with Dr. Carrigan and Jenilee Johnson, the office pharmacy delegate who developed the program to aid patients in tapering and ultimately discontinuing use of both narcotic sleep aids and benzodiazepines. 

Collectively, the team educated patients to the harmful effects of continuing the medication long-term and began to taper their prescription use safely and slowly. Full medication assessments were completed which included a comprehensive intake of their social and past medical history. Patients were assured that their anxiety and sleep needs would be treated with safer alternatives and the team monitored each patient’s progress. In the true spirit of team-based care, other members were often involved including the Chronic Care Management team and pharmacy department.

Due to the communication and education they received, patients understood the concern of long-term usage and were motivated to comply with the program. Upon completion of the program, patients often had the same number of prescriptions, but they no longer required narcotics to help them sleep or deal with their anxiety.

“The pharmacy program has been a tremendous success. Use of benzodiazepines and sleep aids in my practice have decreased by half and are now significantly below the state average. Plus, the patients are very appreciative of the care and consideration shown by our practice and the team approach taken to aid in their care.”

Brian W. Carrigan, MD, FAAFP
Bingham Memorial Hospital

March 2, 2021
Crawford County Memorial Hospital Staff Successfully Emphasizes Diabetes Control
Crawford County Memorial Hospital (Crawford), located in Denison, Iowa has participated in the Caravan Collaborative ACO for three years. Prior to joining the ACO, staff at Crawford had been devoting extra time and resources to their diabetes management program. They hired a clinical health coach and developed a diabetes registry that they used to send care alerts to providers regarding patients who were due or overdue for lab work. 
Shortly after joining the Caravan ACO, they accelerated their focus on the Hemoglobin A1c Poor Control Measure and emphasized the measure in their Chronic Care Management program. While Crawford staff and some providers trained and learned how to transition to value-based care they were met with some challenges. Some providers were hesitant to adopt the new methods but soon saw the value in the program. Most recently, COVID-19 has presented obstacles due to patients not being able to have in-person visits and lab testing but they are successfully overcoming those obstacles.
It isn’t uncommon for patients to resist more testing or appointments but that has not been the case at Crawford. The program initiatives have been well-received by patients and they have adapted well. One of the biggest catalysts in Crawford’s success has been the use of continuous glucose monitoring (CGM). They use CGM to assist in insulin titration, identify hypoglycemia and show patients the effects of food and activity on their blood sugars. Crawford reports that CGM has had a significant impact on improving diabetes control in patients struggling with hyper and/or hypoglycemia. 
Of 68 patients who had a professional CGM device placed between Jan 2019 - Sept 2020, 77% showed a drop in A1C with their next check. Of the patients with an initial A1C of > 9%, 76% had an A1C of <9% with subsequent check. 55% of patients dropped their A1C to <8%.
“(The) Diabetes Management Program has been a tremendous help with patients. The close follow up with CCM has very likely helped avoid ER visits and hospital admissions in a few of my patients. The dedicated case management with reinforcement of education has improved overall satisfaction and confidence in the management of diabetes as well as related health issues like heart failure and hypertension.”
Julie Graeve, ARNP 
Crawford County Memorial Hospital

February 16, 2021
McFarland Clinic Leads Caravan Clients in HCC Recapture Two Years in a Row 

McFarland Clinic (McFarland) joined Caravan’s Stratum Med ACO as founding members in 2019. Comprised of 65 Adult Med and Family Med PCP's, McFarland serves a rural community in Ames, Iowa. When they transitioned to value-based care the McFarland staff worked closely with their Caravan team to place more emphasis on HCC coding. As staff learned to use their new data, they began to recognize opportunities and gaps in care. 

McFarland made the decision to hire Lisa Nelson, a CMA who trained to become an AAPC Certified Risk Adjustment Coder. Lisa's prospective chart review and prep gives McFarland’s providers the confidence that the ICD-10 codes are not only accurate, but also an understanding of the codes that are most important to refresh. With a Risk Adjustment Coder on staff, patient charts accurately reflect known conditions which improves care coordination between the clinic, hospital, and external facilities. Having a more accurate risk score for their population helped increase their benchmarks which lead to more shared savings opportunities. McFarland consistently sees increases in their population HCC risk scores across both Medicare and Medicare Advantage and for the past two years, has led all Caravan Health clients with their HCC recapture rates. 

In 2020, 88% of McFarland’s patients were coded with one or more of the following: CHF, Diabetes with or without complications, Specified Heart Arrhythmias, COPD and Vascular Disease. 

Learn from the leaders: McFarland’s HCC Process: 

1. Employ a AAPC Certified Risk-Adjustment Coder in population health. 

2. Provide a daily list of patients with upcoming PCP visits for coder to review. 

3. The patient list is prioritized by highest outstanding HCC value including both known HCC's in Epic and HCC's found in Medicare claims history but not in Epic. 

4. Coder edits the problem list where appropriate and flags HCC's for provider review and documentation during the visit. 

5. HCC's are auto-flagged for providers by Epic when due for refresh based on past billing or problem list. 

6. Coder selects a number of past visits to audit every day to check for adequate documentation and periodically provides results to the provider documentation/coding education team. 

“At McFarland Clinic, providers are responsible for their own coding, both CPT and ICD-10. The automated HCC alerts in Epic helped improve our HCC recapture.” 

Austin Lepper, Director of Population Health 
McFarland Clinic 

February 9, 2021
Oregon-based Practice Tracks Hypertension Data to Improve Care Delivery

Cascade Internal Medicine (Cascade), has participated in the Caravan Collaborative ACO since 2018. Due in part to the expertise of Dr. Mark Backus, a blood pressure champion, the clinic has always had an interest in addressing hypertension. Clinic staff and providers recognize that hypertension is a major risk factor for other health concerns which drives their motivation to address this “silent killer” in their patient population. The catalyst, however, to strive for even better patient outcomes was their participation in Caravan’s ACO and CPC+ programs.
The clinic began identifying patients who did not meet the threshold for hypertension control. To overcome potential patient resistance to returning to the office for rechecks, the clinic increased their outreach and encouraged patients to come in for blood pressure checks. To improve access to appointments they offered a ‘quick visit’ option with a medical assistant to reassess medications, lifestyle changes, and other relevant actions. Each conversation with the patient reinforced the message that high blood pressure effects their overall health. The clinic invested in a robust hypertension monitoring program that allowed patients to go home with blood pressure cuffs and log their daily pressures.
As patients began to engage and understand the importance of preventing serious side effects, they responded with enthusiasm. In the three years that Cascade has committed to this program, they have seen significant improvements. As they track data, they make adjustments to continue their goal of improving how they deliver care.
Percentage of Cascade patients with controlled hypertension:
2018: 79.9%
2019: 83.6%
2020: 89.3%
Key Takeaways from Cascade’s Successful Hypertension Control Program:

  • Investing in high-quality automatic blood pressure cuffs provides the opportunity for multiple patient readings during a visit which can be performed by medical assistants.
  • Offer educational resources to patients so they can better understand how to obtain and document accurate blood pressure readings.
  • Engage patients and communicate the importance of controlling hypertension and the effects that high blood pressure has on their overall health. Openly discuss lifestyle changes, help them create goals and follow up with outreach.

February 2, 2021
Accountable Care Case Management Leads to Life-Saving Experience

Confluence Health | Wenatchee Valley Hospital and Clinics (Confluence) have been members of the Stratum ACO since 2019 – long enough to have established value-based models of care. Confluence serves an expansive rural area in the state of Washington, an area hit hard by COVID-19.
Confluence quickly recognized that with many in-person services being shut down that their patients, and specifically their vulnerable populations, had the potential to be very isolated during the quarantine and social distancing mandates. As they transitioned to virtual care, they also noted that their Medicare population was not as technologically savvy and therefore less likely to access telehealth. With this knowledge, the case management staff placed a high emphasis on personal outreach in hopes to help patients feel supported and connect them with the care, services, or resources when indicated.
In one example, a outpatient had been diagnosed with COVID-19 and lived alone. The case manager called each day and deployed COVID-19 case management workflows overnight. As the case manager continued to call, she noted that the patient had become extremely sick and unable to get out of bed and was no longer returning calls. The Confluence team stepped in and had the patient admitted to the hospital. As the patient slowly began to improve, she thanked the case manager for her persistent outreach. When asked about her case manager the patient commented, “I would have died in bed had she not left multiple messages that day checking in – the case manager saved my life.”
“The organization as a whole recognized how specifically case management services and staff have the capacity and skill sets to connect with individuals in the community to engage them in this type of support. We as case managers, have a very specific niche for reaching out and collaborating with patients in the community setting, which is unlike any other service our clinic provides. Due to this, patients are very welcoming and grateful to receive this outreach and feel that we care for them as an individual, making them eager to enroll in this service.”
Tabitha Miller, RN

January 26, 2021
Marcus Daly Memorial Hospital Increases Depression Screenings by 60% in 12 Months
Located in Montana, the state with the unfortunate distinction of often having the highest suicide rate in the nation, Marcus Daly Memorial Hospital (Marcus Daly), serves a community that was weighed down by a recent teenage suicide. Members of the Caravan Collaborative ACO since 2016, staff and providers at Marcus Daly collectively agreed, “enough already.” 
Marcus Daly had established a team to focus on improving certain quality measures as part of their ACO goals. Working in concert with Caravan Health, they began to identify gaps in care, and it was clear that there was room for improvement on the Depression Screening and Follow-up Measure. The team immediately went to work to identify patients who had exhibited signs and symptoms of depression. They quickly learned that to make meaningful change in someone’s life who is battling depression, their approach needed to encompass more than treating the symptom. 
Using best practice population health techniques staff worked to overcome the stigma of talking about depression, including, at times, their own hesitancy to ask patients the PHQ-2 and PHQ-9 screening questions. It is a common challenge as staff often have to balance asking uncomfortable questions with keeping patients engaged. Staff, however, embraced the screenings, made the conversations more comfortable and included resources and printed materials when appropriate. They did not stop there. They implemented depression screenings in the ED, inpatient, swingbed, specialty and rural health clinics.
By the end of 2019, Marcus Daly reported a 60% increase in the Depression Screening and improved their rates of follow-up for those patients who tested positive. As the COVID-19 pandemic disrupted health care delivery everywhere, Marcus Daly staff continued their screenings resulting in positive change in their community. Today, Marcus Daly is working toward implementing a Behavioral Health Integration Program as they continue to emphasize the importance of mental health.

Marcus Daly Tips to Improve Depression Screening & Follow-up Quality Measures

  • Create a committed interdisciplinary team that will meet regularly with a clear scope of the project.
  • A change in facility culture may be required regarding mental health.
  • The facts on depression are sobering and you need buy-in from front line staff by educating them on the importance of the screening measures. 
  • Reach out to your state public health or national organizations for additional information and resources if needed.  
  • Take care of your employees and co-workers. Remember, your employees and providers represent your community, and your own employees may have depression or may even be contemplating suicide. If you don’t take care of your own, they can’t take care of the community.
  • Select a provider champion to talk to the other providers to roll out the plan, gain feedback on what is and is not working, and provide support.
  • Do not make Depression Screening the ‘Flavor of the Month’. Create a plan that will continue to monitor that screenings are occurring, and providers have the resources to help the patients. 

“We’ve gleaned information from our state resources and depression is one of the most treatable of all psychiatric disorders. Even more sobering is that up to 45% of individuals who die by suicide visit their primary care provider within a month of their death, with 20% of those having visited their primary care provider within 24 hours of their death. We were determined to improve our Depression Screening and Follow up Measures.”

Mira McMasters, CPHQ 
Quality Director
Marcus Daly Memorial Hospital

January 25, 2021
In a Community with Higher-than-Average Smoking Rates, Allen Parish Healthcare is Committed to Smoking Cessation Measures

Allen Parish Healthcare, part of the Caravan Health Crouse ACO, serves a rural community in Louisiana, a state with the third highest smoking rate in the nation. Only West Virginia and Kentucky report higher rates of smoking. According to the CDC, tobacco smoking remains the leading cause of preventable death and disease in the U.S. Cigarette smoking kills nearly 500,000 Americans every year.

In Louisiana, 22% of adults smoke. Aware of their higher-than-average rates, staff and providers at Allen Parish are committed to the Tobacco Screening and Cessation Intervention quality measure to help reduce smoking rates in their patients and community.

As part of an ongoing quality improvement effort, Meaningful Use incentive, the staff communicates with patients and asks about their smoking status and informs them of tobacco cessation counseling, educational resources, and enhanced wellness visits to help encourage them to stop smoking or to reduce their usage. With the goal of having fewer active smoking patients, the staff implemented a way to capture each patient’s status in order to flag their provider to discuss the merits of tobacco counseling. They rely on their EMR to track their visits and increase the productivity and efficiency of their conversations – continuing to convey the importance of smoking cessation. With the EMR, each team member is able to see prompts to follow up and include specific measures as part of their workflows. Together, staff, providers and patients work toward achieving the collective goal of reducing or stopping smoking.
Despite being in an area with a high rate of smokers, Allen Parish patients have been cooperative and open to utilizing the resources to help them stop or reduce their smoking and have expressed an openness to screenings and cessation interventions. Today, Allen Parish reports that 92.9% of their patients have been screened and received intervention materials.
“Tobacco cessation and counseling reduces risk for many adverse health effects, including poor reproductive health outcomes, cardiovascular diseases, COPD, and cancer. Our clinic and providers have adopted a new vision for our clinic to promote wellness and educate our patients on the importance of being healthy in all aspects. It truly is a team effort in providing wellness care and promoting healthy living to our patients, and our team at Allen Parish Community Healthcare continues to strive to keep our patients healthy.”
Alex Courville, M.D.
ACO Provider Champion
Allen Parish Community Healthcare

January 13, 2021
Mammoth Hospital Uses Patient Engagement Techniques to Help Patients with Depression 

Since 2016, Mammoth Hospital (“Mammoth”), which serves the largely dispersed, rural communities of Mammoth Lakes, has been a part of a Caravan ACO. Rural residency is commonly cited as a risk factor for depression and providers at Mammoth, well-versed in population health practices, routinely take proactive measures to screen, prevent, and treat depression in their rural area.

Recently, during the COVID-19 pandemic and in the midst of social distancing and quarantining measures, a patient presented with a PHQ-9 score of 20 and a GAD-7 score of 3. He was diagnosed with a Major Depressive Disorder, ingle episode, severe with noted relationship problems and nicotine dependence. Mammoth providers initiated treatment that included a combination of in-person and telehealth visits. After four visits his symptoms had notably decreased and his PHQ9 score was a 6 – in the mild depression range.

The symptoms of depression including low motivation and energy often preclude patients from continuing treatment. As is common, this patient stopped attending visits. Mammoth staff, however, using best practice methodologies, re-engaged the patient and noted his scores had fallen to the moderately severe range with a score of 18. Mammoth staff continued to engage the patient, this time with a psychiatric consultation and medication assessment. Staff also encouraged the patient to attend in-person visits to help offset the isolation.

In a relatively short period of time with consistent visits and enhanced engagement, the patient’s PHQ-9 scores returned to the mild range and he was effectively weaned from medication. Population health nurses have worked with the patient to identify his goals to help him find more meaning in his life. The staff have helped him improve his communication style, increase self-compassion, decrease his nicotine use, and establish healthy habits and behaviors. His depression score continues to improve and today is near the normal range. 

The Top 3 Takeaways from this Patient Success Story
1. Continue to contact a patient with depression, engage and re-engage as much as necessary.
2. Despite the health and safety benefits of telehealth, patients with depression may require more in-person visits to help keep them engaged and motivated to get better.
3. Population health best practices such as helping a person with depression set goals and find meaning will help create new patterns of behavior and thinking.

“When a patient has depression, it is important to understand that the symptoms of their illness often prevent them from returning calls and/or engaging in appointments. We knew his depression impacted his motivation and we took steps to reach out to him and worked to encourage him to attend virtual appointments. Eventually the appointments transitioned to in-person. Our efforts helped keep him be more engaged, especially through his lowest points.”

Dr. Jacob Eide, Behavioral Health Clinical Supervisor

Recent Resources

CMS Actions in Response to the COVID-19 Public Health Emergency

The Centers for Medicare and Medicaid Services just issued a lengthy set of policy changes to address the growing COVID-19 public health emergency (PHE). These changes will help hospitals and health providers to respond to the crisis more quickly and safely, including many more options for telehealth in Medicare.

ACO, Policy, Webinars & Events, Quality, Value-Based Care, COVID-19

Stop Standing Still: How to Get Started in a High-Performing Caravan Health ACO

Tuesday, September 24 at 9:00am PT / 12:00pm ET

ACO, Webinars & Events

10 Reasons ACOs Can Fail

Just published in Becker’s Hospital Review – Caravan Health Senior Vice President Tim Gronniger discusses ten reasons Accountable Care Organizations can fail.

ACO, Blogs & News, Value-Based Care


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