September 28, 2021
Opelousas General Health Systems Increases Rates of AWVs Using Caravan Health Resources 

Opelousas General Health System (Opelousas) is based in Opelousas, LA, and has partnered with Caravan Health since 2019. When Opelousas began emphasizing the importance of the Annual Wellness Visit (AWV) to improve workflow efficiencies and identify potential gaps in care, they used one of the more popular resources at Caravan Health: The Annual Wellness Visit Guidebook.
From the onset, Opelousas staff found the Guidebook to be helpful. The Table of Contents showcased the topics listed in each chapter and were detailed enough to allow them to ‘search and find’ the exact subjects and steps they wanted. But, as the staff quickly realized, this resource was able to supplement their AWV trainings and aligned with their increasing knowledge base. 
Rather than be overwhelmed with new population health methodologies, clinic staff were empowered to launch their AWV approaches according to their particular patient demographic yet complying with the standardized workflows that had been proven to be effective with other Caravan Health clients. Clinic managers and staff offered feedback during the trainings which led to a successful and smooth implementation. The Opelousas staff appreciated that each section was written and presented to the varying team members, was specific to each role and did not include more information than necessary which could lead to confusion or misunderstanding.  
As they ​​completed the Caravan Health training, the Medical Assistant and Population Health Nurses appreciated the instructions for visit prep and completion and were presented with useful, strategic steps. The reception staff benefitted from the overarching introduction to team-based care and learning why the AWV is essential to population health. Providers relied on the Guidebook to learn more about diagnosis reconciliation, advance care planning (ACP) and HCC coding and billing for preventive care. 
Having successfully completed rounds of training and implementation, Opelousas has moved forward and beginning to see results. Since January 2021, Opelousas has increased their rate of AWVs from 39.1% to 47.3% and increased their rate of ACP from 24.1% to 29.7%. 
“We are on a continuous mission to improve our quality of care with our team-based approaches. Caravan’s Annual Wellness Visit Guidebook has proven to be an essential resource to us. The content effectively showcases the information necessary for our staff to absorb and put into action.” 
Andrea Philippi, BSN, RN, CCM 
Population Health Nurse 
Opelousas General Health System


September 21, 2021
Winona Health Captures 340B Success with Caravan Coach 

Winona Health (Winona) has served its rural Minnesota community for the past 126 years and are known as an all-inclusive health care organization delivering care from birth to death. Winona has a 49-bed inpatient hospital, a long-term care facility, an offsite memory care home and offsite clinics.  
Due to Winona’s successful experience participating in the Caravan Collaborative ACO, when the 340B opportunity presented itself, Chief Operating Officer, Robin Hoag made the decision to learn more. She engaged her pharmacy staff and together they worked with their Caravan partners to learn more. They did not have a lot of prior experience or 340B knowledge. They admit to being initial skeptics – it sounded too good to be true that they could claim some of the prescriptions being written by their contract pharmacies by outside providers.  
A proven win-win 

Prior to becoming involved with Caravan, Winona’s 340B program consisted of five contract retail pharmacies located in their town. After learning of the savings potential, they worked closely with Caravan to optimize their opportunities. Today, Winona’s 340B program has expanded to 40 different locations including mail order and specialty long-term care pharmacies.  
Due to their newfound knowledge and understanding, Winona staff and providers have expanded their professional relationship beyond a medications list. They are able to share more information with their partners and this communication has opened up new treatment options and opportunities for patients – particularly in the realm of behavioral health. They have identified gaps in care and potential medication replication which could have been detrimental. 
Winona has used Caravan Coach to increase capture rates by identifying every possible prescription that could potentially be included in the program. Winona evaluates claims and all the documentation to ensure they are maintaining optimal levels of compliance. They have implemented their 340B program and enhanced it with Coach and the combination is proving to be a success.  
“Our 340B program has become a completely different program with so much more opportunity. And not just for capturing revenue, but in coordinating care with our patients and providers. It’s closing the loop on some patients.” 
Robin Hoag 
Chief Operating Officer 
Winona Health


September 14, 2021
Frances Mahon Deaconess Hospital Uses Preventive Care to Improve Patient Outcomes
Serving a patient population in Glasgow, MT, France Mahon Deaconess Hospital (FMDH) has partnered with Caravan Health since 2016. FMDH is a participant in Caravan’s Collaborative ACO. 
In 2019, FMDH implemented a new EMR and began to capture and report quality measures. For data capture of the fall risk assessment FMDH staff added the required assessment in the intake portion of the progress note near the chief complaint for all visits with patients aged 65 and over. Nursing staff were asked to observe the patient as they were escorted to the exam room and to notice if they require an assistive device or if they noted problems with their gait.  
Prior to implementing the workflow and documentation changes, 78% of this cohort of FMDH patients had documentation that a fall risk screen had been completed. Following implementation of the new workflow, 94% of patients had documentation that a fall risk screen had been completed. This is a significant increase in the number of patients screened for fall risk. Screening patients for fall risk is a key element to preventive care and helps FMDH staff identify opportunities to intervene prior to a fall. 
Lessons Learned
The biggest challenge for FMDH was to build the required elements and successfully mapping them in the EMR in order for the reports to correctly reflect the denominator and numerator. Nick Dirkes, Director of Planning, ensured that the FMDH documentation and reporting was streamlined and user-friendly which has proven to be an essential component of their success. 
The majority of the patients have a negative screen which requires no action. For those with a positive screen, staff make referrals to PT and/or recommend exercises and provide resources so patients can improve their balance and strength at home. 
“Falls are the leading cause of fatal and nonfatal injuries for our patients aged 65 and older. Identifying fall risk and preventing falls is a low cost, high-yield strategy for improving health care. This is at the core of our population health workflows.”       
Nick Dirkes, Director of Planning 
Frances Mahon Deaconess Hospital

September 1, 2021
Hutchinson Clinic Removes Barriers So Patients Have Easy Access to Preventive Care 

The Centers for Disease Control and Prevention (CDC) recommends that people get a flu vaccine by the end of October. However, they state that by getting the vaccination early, in July or August, is likely to be associated with reduced protection against flu infection later in the flu season – particularly among older adults.  
Based in Hutchinson, Kansas, the Hutchinson Clinic (Hutchinson), joined Caravan Health’s Stratum Med ACO in 2019. Staff and providers at Hutchinson are proactive with educating their patients about the merits of preventive care and one of those initiatives is encouraging their patients to get the flu vaccine. 
Hutchinson’s Flu Vaccine 7 Best Practices
Education & Marketing: Hutchinson commits to promoting their flu shot clinics and flu vaccine availability. They engage in social media, radio, flyers, posters, outdoor banners, and lawn signs to promote the flu vaccine. 
Flu Shot Clinics: Hutchinson offers multiple flu vaccine clinics at convenient times and locations including walk-up and drive thru. One pediatric flu clinic is scheduled during evening hours with extra pediatric nurses available.  
Immunization Registry:  Through the Kansas Health Information Network, Hutchinson can import vaccine records from other facilities. Any time a patient has an encounter, the registry is queried, and vaccine data is automatically imported to the EHR. 
On-Site Flu Vaccine Clinics for Corporate Partners: Hutchinson partners with employers in surrounding communities and makes on-site visits to administer flu vaccine to their employees – all which are documented in the EHR. 
Pharmacy: An onsite pharmacy at one location offers flu vaccines. Hutchinson’s pharmacy staff administers vaccines and documents in the EHR. 
QIS Reminder: A current year flu metric has been added to Hutchinson’s EHR to identify care gaps and mark reminders. Staff communicate to ensure the patient is reminded to get the vaccine. 
Walk-in Care: Hours at Hutchinson’s primary walk-in care clinic are extended, and patients can receive the vaccine anytime the clinic is open. 
“At Hutchinson, we make a concerted effort to remove barriers and offer easy access for patients to receive the influenza vaccine. This requires cooperation and communication across many clinic departments and results in more of our patients receiving preventive care.”  
Lisa Jensen RN, BSN 
Clinical Quality Coord

August 26, 2021
A Holistic Population Health Approach is the Key to Patient Success at Tampa General Hospital 

In 2019, Tampa General Hospital (TGH) joined the Caravan Collaborative ACO. The urban hospital embraced population health and recently shared an example of patient success and improved outcomes.  

A 54-year-old female patient with a complicated history of Type 2 diabetes mellitus with hyperglycemia, with long-term current use of insulin, Hyperlipidemia, Hypertension, Morbid obesity with BMI of 70 and over, and adult and NASH (nonalcoholic steatohepatitis).  When the patient enrolled in TGH’s Chronic Care Management program her blood sugars were in the high 300’s, her ammonia levels were causing severe confusion and hallucinations, and she was either in the emergency room or the hospital at least once a month.  

Patient did not express motivation to change her behaviors. Her health care insurance was mediocre and due to the costs, she was not filling her prescription medication. The population health team including a clinic pharmacist and population health nurse intervened and established a more cohesive relationship with the patient that opened the doors of communication. 

At its core, population health is holistic care and takes the entire patient picture into account by using a team-based approach. In the case of this patient, multiple health care teams and professionals came together for the benefit of the patient. They started with optimizing her prescriptions through medication reviews and finding more affordable medication by scheduling appointments with TGH’s liver transplant team which gave her access to 340B pricing.  

With open communication and a ‘meet the patient where she is’ approach, the patient began to be more engaged and incorporated healthy lifestyle changes. She adheres to her medication regimen and her emergency room and hospital admission rates have dropped significantly.  

Most recently, her blood sugars dropped from the 300’s with an A1C of 10.3 to a current A1c of 7.8, with most fasting blood sugars remaining below 140. Her cholesterol has gone from 144 to 127, triglycerides dropped from 148 to 116, and her AIC goal was met. 

“With population health, we’re able to dive deeper with patients and get to know them on an all-new level. The extra time spent with them is making a difference. We’re improving our outcomes and our patients are taking ownership of their own health. It’s a win-win.” 

Adrienne Holmes BSN, RN 

Tampa General Hospital 

August 10, 2021
Community Memorial Health Systems Use Team-based Care to Address Social Determinants 

Community Memorial Health System (CMHS) joined the Caravan Health Collaborative ACO in 2021. The Ventura, California-based health system includes a 242-bed hospital which also serves as a community-based teaching facility. 

Accountable health care incorporates a range of population health methodologies including a team-based care approach. Team-based care involves a variety of health care professionals, including office personnel and CNA’s who often help to identify patient needs.  

Recently, CMHS’s Chronic Care Management team referred a patient in acute need to a Case Manager. The patient, who had cirrhosis of the liver, was extremely ill. He was living in his car and suicidal. He had a history of repeated visits to the ED which is indicative of a chronic issue and can be very costly for a facility. 

Research has shown that in some cases, social determinants can be more important than health care or lifestyle choices in influencing health. For example, according to the World Health Organization, numerous studies suggest that social determinants of health account for between 30 and 55% of health outcomes. Providers and staff at CMHS understand that addressing the social determinants of health is fundamental to improving health and reducing longstanding inequities – like experiencing homeless and suicidal ideations. 

The CMHS Case Manager immediately went to work for the patient and secured housing for him under a special homeless assistance project. In addition to housing assistance, the Case Manager started the process of helping him to apply for disability benefits, referred him to food pantries and kitchens, and enrolled him into the CMHS Behavioral Health Integration program. 

Today the patient’s health and housing have been stabilized. He is being treated for his cirrhosis and also seeing a psychiatrist. He is receiving long-term disability which is helping him to maintain his housing. CMHS staff continue to work together in a team-based approach to improving patient outcomes.  

“Through our population health methodologies, we identified a patient experiencing homelessness who was repeatedly going to the ED and we intervened. Repeated ED visits are always a sign of a more comprehensive problem. Our High-Risk Case Manager helped get the patient in a stable medical situation and worked with other social service teams to provide resources and support.” 

Maureen Hodge 
Manager High Risk
Community Memorial Health System 

August 3, 2021
Communication is Key to Madison Healthcare Services CCM Success

Madison Healthcare Services (Madison) is a Rural Health Clinic located in Madison, Minnesota and has been with Caravan Health since 2016. As part of the Caravan Health Collaborative ACO, staff and providers at Madison were quick to transition to a holistic care model and implemented a team-based approach to caring for and treating their patients.  

Recognizing that one component to improved patient outcomes is through a successful Chronic Care Management (CCM) program, Madison emphasized increasing the numbers of patients enrolled in CCM. Madison’s team-based approach includes having LPNs and CNAs complete AWV forms to help identify key points for the providers on CCM eligible patients. These points are reviewed by the provider with the patient and not only helps to maintain a continuity of care but also a continuity of communication between the staff, patient, and provider. 

These seemingly simple steps have resulted in better physician engagement. Physicians are able to spend more time with the patient and able to discuss the importance of CCM which effectively creates a warm hand-off to the population health nurses. This step sets everyone up for success.  

As Madison continues to improve its CCM program,. population health nurses work closely with patients who are mostly elderly. These patients now feel so supported and engaged that they proactively call the nurse each month, taking ownership of their health and care plan. The population health nurses have given these patients the confidence to take the initiative with their care.  

One factor that has proven to be crucial to Madison’s CCM team-based success is communication. Gone are the ineffective silos that prevent providers and health care professionals from accessing patient information and in turn, patients have easy access to their health care team. The staff tracks readmission rates and gleans data from Coach to further identify patients who quality for CCM.  

“Since implementing team-based care at Madison, we’ve seen an improvement in communicative care. It’s as if the nurses are the arms of the providers – everyone is working together, and our patients comment on how supported they feel.”  

Kris Monson, RN  
Clinic Manager
Madison Healthcare Services 

July 27, 2021
Fisher-Titus Medical Center Emphasizes Transitional Care Management to Improve Outcomes 
In 2016, Fisher-Titus Medical Center (Fisher-Titus) made the decision to transition to value-based care and joined a Caravan Health ACO. Fisher Titus delivers high quality health care to residents of Norwalk, Ohio, by opening avenues of communication and aligning departmental teams to best serve their patients in transitional care. 

The Transitional Care Management (TCM) success at Fisher-Titus is founded in the support system that starts at the executive level. In 2020, Brent Burkey, MD, President and CEO, suggested that staff and providers align their chronic care navigators under the quality division that also oversees inpatient case managers. The alignment successfully removed the siloed experience that was occurring between inpatient and ambulatory offices. The move successfully opened the doors of full transparency and communication between inpatient case managers and chronic care navigators. This resulted in an improved focus on the transition of care and the assurance that chronic care navigators are aware of all inpatient discharges and conditions related to that inpatient stay.  

Fisher-Titus has implemented additional initiatives that help set the stage for TCM success including:  
  • Quarterly meetings are held with all post-acute providers, skilled nursing facilities, and home health organizations. The meetings help to ensure that chronic care navigators are notified of all patient discharges assigned to ambulatory offices within 24 hours. This initiative has proven to be effective with patient follow-up appointments and automatic communication if a notification is missed.  
  • Health information exchanges are checked daily for outside discharges from tertiary hospitals and post-acute facilities.  
Results of improved TCM at Fisher-Titus:
  • Fisher-Titus’ 7 and 30-day Medicare ED utilization has decreased.  
  • Patients enjoy the weekly calls from their navigators which has led to increased enrollment in the Chronic Care Management program. 
“The most important advice I could give to anyone considering accountable care and a team-based approach is to get your senior leaders on board, along with the Ambulatory Medical Director. They become your biggest champions.” 
Karen Dickinson 
Vice President Quality 
July 20, 2021
Hancock Regional Health Helps Patients Address Medical & Social Challenges to Improve Outcomes

In Greenfield, Indiana, Hancock Regional Health (Hancock) delivers high-quality, value-based care to their community. The full-service health care network has participated in a Caravan Health ACO since 2015 and are current members of the SHO ACO.

With staff and providers well-versed in the nuances of population health, Hancock understands that patient compliance may not always be what it seems – sometimes social determinants of health (SDoH) are at play. The health system works in concert with Healthy 365 (H365), their social services department, and their Care Coordination team to make sure patients have the resources to address obstacles that prevent them from accessing health. In some situations, patients who may present as being non-complaint are dealing with challenges that keep them from being compliant and many do not know they can discuss these challenges with their providers.

Population Health Makes a Difference
A patient at Hancock presented as non-compliant with a suggested medical regime. In other, non-population health facilities, the patient would likely have been labeled as non-compliant. However at Hancock, the staff wanted to learn why the patient – who seemed interested in following through with instructions – was not doing so. After a conversation with the patient using population health methodologies, the population heath nurse discovered that the patient was struggling to pay their monthly rent. With money tight, the patient could not justify spending the money on transportation to the office when it could jeopardize her housing. 
In this case and many similar, the Care Coordination team communicated with the H365 team. Together, they discussed the challenges the patient was facing. The H365 team stepped in to assist the patient in applying for financial assistance. They also coordinated rental assistance and worked with the patient to identify other social determinant challenges.

Population Health Takes a Team
Hancock recognizes that comprehensive team-based care helps improve outcomes by not only focusing on their patient’s medical needs but by also placing emphasis on their patient’s social needs. Hancock holds a quarterly meeting with their 50 social service providers to discuss new programs or problems encountered while seeking services. In addition, a care team manager attends a monthly board meeting to ensure a continuity of care through a continuity of communication.

“At Hancock we understand that our patient’s health is comprehensive and in some cases that includes addressing social determinants of health. If a patient presents as non-compliant, we learn the core cause of their non-compliance and work to overcome the challenges together.”
Susan Neely, RN, MSN
Chief Clinical Officer
Hancock Regional Health

Henry County Memorial Hospital Utilizes Caravan Coach to Identify At-Risk Patients
July 13, 2021

Henry County Memorial Hospital (Henry County) delivers comprehensive health care services to residents of New Castle, Indiana. Members of the SHO ACO, Henry County has participated in a Caravan Health ACO since 2015.

Health care staff and providers at Henry County set a goal to increase their CCM program and enroll more patients who would benefit from chronic care management. With the introduction of Caravan Coach, the comprehensive platform for patient care, the collective team at Henry County learned through training sessions they could generate patient reports based on disease cohorts. 

“We decided to start with our COPD population,” commented Ashley Reno, RN, Care Coordinator. Indeed, Coach data indicates if patients are at low, medium, or high risk. “We decided that our low to medium risk COPD population would be most appropriate for outreach and CCM services. We have
found that most of the high risk patients in this COPD population are currently engaged with us or do not qualify for services.”

Ashley began reviewing their low-to-medium risk COPD patient population and immediately identified a patient who was appropriate for outreach. The patient had recently suffered from a Cerebral Vascular Accident (CVA) and during a chart review, it was noted she had been hospitalized at an outside facility. The discharging hospital sent this patient’s PCP a fax cover sheet stating to schedule a follow up appointment with this patient for hospital release. The discharging facility, however, did not send a discharge summary. This patient was not scheduled for hospital release, the request was not added into the EHR and was unfortunately missed. 

After piecing the bits of information together, Ashley contacted the patient for hospital release follow up call and offered her CCM services. As they talked, Ashley discovered the patient had multiple specialty appointments, and had difficulty tracking her appointments. She suffered from some vision loss in relation to the stroke, so she has a barrier with reading and managing her medications. 

“Thankfully, I was able to obtain the patient’s discharge summary in the care web portal.
I discussed the hospitalization and the patient’s barriers with her PCP and collaborated with staff to schedule the patient an appointment for her hospital release. It was then I was able to meet this patient face-to-face,” added Ashley.

The Henry County staff has been engaged with the patient for a few months and the patient is improving. She has learned how to track appointments and is understanding the importance of taking her medications. With the help of her health care providers, she is managing her chronic conditions. The patient is also learning the importance of following up with her specialty providers.

Today the patient is extremely engaged and motivated to stay well and healthy. “If this cohort wasn’t utilized in the way we are using it, this patient could have potentially suffered from further complications,” concluded Ashley.

The Iowa Clinic Integrates Chronic Care Management with Behavioral Health to Benefit Patients
June 22, 2021

The Iowa Clinic (TIC) offers comprehensive medical care to the community of Des Moines, with 250 providers who represent 40 specialties. TIC has participated in the Caravan Health Stratum Med ACO since July 2019.

According to the Center for Infectious Disease Research & Policy, (CIDRAP), rates of depression have tripled in U.S. adults during the pandemic amid COVID-19 stressors. In fact, one study reports the rise in depression to be much higher than after previous major traumatic events. Prior to the pandemic, 8.5% of adults reported depression symptoms and in stark contrast, 27.8% reported depression symptoms during the pandemic. CIDRAP also demonstrates that the burdens of depression have increased significantly. Historically, American females experience higher rates of depression than American males, 10% compared to 7%. However, during the pandemic, the rates of females who reported depression symptoms increased to 22.2% and symptoms in males jumped to 21.9%.

Staff and providers at TIC actively enroll qualifying patients in their chronic care management (CCM) program for chronic condition care, including depression. In a recent case, a 65-year-old female was enrolled in CCM for management support of diabetes and depression. The patient had been experiencing depression since her lifestyle was dramatically changed during the pandemic. She was also struggling with debilitating anxiety. 

This patient expressed to her care manager how frightened she was to be in public and afraid to go out and get the vaccine which was being offered in a community pharmacy. She had high anxiety about getting sick by being in close proximity to others who were receiving the shot in the small pharmacy. In her evaluation of the concomitant levels of depression and anxiety in the patient, the TIC nurse not only scheduled her for a vaccination appointment at TIC where there would be fewer people, but she also accompanied the patient on her visit to help ease her anxiety. The nurse was on hand to explain the patient’s situation to the professional who was administering the shot and therefore he was well-informed and helped to further ease her anxiety and make her as comfortable as possible.

The nurse also provided the patient with educational resources on relaxation and grounding techniques to help manage her anxiety. These population health techniques helped the patient to be more at ease and comfortable returning for her second dose.
“Our chronic care management program is comprehensive. It crosses into behavioral health management and overall health and well-being whenever indicated. This program is successful because we meet the patient where they are and help them learn to better manage illnesses and whatever they may be dealing with.”
Christine Taets, RN
Care Manager
The Iowa Clinic

Bay Clinic Addresses Food Insecurity with a Veggie Rx ‘Farmacy’
June 15, 2021

Since July 2019, the Bay Clinic has participated in a Caravan Health ACO, and staff and providers place an emphasis on improving population health. When their Social Health Department Director, Sarah Cornelison, read about a neighboring community health improvement plan she wanted to learn more about implementing a Veggie Rx program for their patients experiencing food insecurity. 

Working with the local food bank to provide fresh foods, they partnered with a non-profit corporation that provides assessment, training, and employment of people with disabilities in various capacities. They worked together to secure refrigerators and food sources. Staff and providers started using a SDOH screening tool and chronic disease diagnoses as criteria to qualify patients for fresh veggie assistance.

Bay Clinic’s Veggie Rx Farmacy has been in full operation since mid-January 2021. After a provider identifies an unmet need, a referral is sent to the Social Health Department who works with the patient to establish goals. Any patient who meets the criteria and wants to participate can receive services through the Veggie Rx Farmacy. Each patient receives a portion plate, reusable produce bag, information packets based on the reason for referral and decorated water bottles and pencils and stickers featuring fun vegetables for children. 

Since the program began, Bay Clinic has served an average of 60 or more patients and their families every Thursday. Despite having a designated date and schedule for the Farmacy, patients are never turned away regardless of the day when there is a need.
Patients participate for multiple reasons and range in age from pediatrics to adults. Some want to lose weight and need access to fresh vegetables; others need to gain weight but need to avoid items high in sodium due to diagnoses such as congestive heart failure. Families enjoy bringing their children and spouses to select and discuss new and different types of fruits and vegetable available. Patients have sent the staff pictures of the foods they have cooked at home using the produce. The Veggie Rx program has been an overwhelming success. 

For anyone interested in starting a Veggie Rx program, the Bay Clinic staff recommends contacting local food share services to learn how your office could set up a pantry or Veggie Rx Farmacy program to fight hunger and help prevent social determinants related to food insecurity. Partnering with a non-profit helps to reach more patients with fresh fruits and vegetables. 

“We identified the need our patients had to access fresh fruits and vegetables. With limited community transportation playing a factor in our rural area, we worked to develop a program that would minimize the transportation problems of our patients and allow them the ability to access a food pantry for those with food insecurity and a Veggie RX ‘Farmacy’ program for those on a limited budget with health-related determinants within their medical home. We are truly putting population health into action and working to not only screen for social determinants of heath but to also build solutions to the problems”.
Sarah Cornelison CCMA, CCHW 
Social Health Department Director
Bay Clinic
“Out of the numerous things I do in care coordination for families, the Veggie Rx program is the most rewarding. I love seeing patient’s faces light up when they see all of the new produce we have.” 
Heather Garrett
Certified Community Health Worker
Bay Clinic
Olmsted Medical Center Focuses on Advance Care Planning to Improve Patient Care
June 8, 2021

Olmsted Medical Center (OMC), serves the community of Rochester, MN and has participated in a Caravan Health ACO since 2016. Staff and providers at OMC have implemented Advance Care Planning (ACP) into their daily workflows as a way to carry out their mission to deliver exceptional patient care by focusing on caring, quality, safety, and service. ACP is also a way to approach population health management. 
OMC’s successful ACP has been a gateway to improved patient outcomes and has also enhanced financial outcomes. How did they do it? Below are some highlights: 
  • OMC developed a Multidisciplinary Workgroup comprised of nursing & social services who meet weekly to discuss shared goals & patient progress.
  • They increased the awareness & importance of ACP by educating clinicians & support staff with consistent all-staff emails, grand rounds, departmental meetings, intranet communications & internal campaign letters.
  • Staff partnered with IT teams to standardize documentation processes around ACP conversations with patients in their EMR. 
  • They also partnered with their health information management department to develop a process that flags some documents for further review & contact with the patient.
  • OMC enhanced its rooming standards within the ambulatory care departments to include an introduction to ACP.
  • They developed a robust audit process which allows them to provide one-on-one education when gaps are identified with certain care teams.
  • Their social services department has actively engaged with community stakeholders to gather information on how ACP is presented in their facilities.
  • OMC set a specific goal to increase the number of advanced healthcare directives on-file by 50% over the baseline number by the end of 2021.
As the staff and providers work in concert on their ACP goals, they are continuing to strengthen the addition of a follow-up procedure with patients who submitted invalid ACP documents. At nearly the mid-point of the year, OCP is on track to meet their goal.
A Before|After Look at Team-based Care at Bibb Medical Center
June 2, 2021
Prior to joining a Caravan Health ACO in 2021, the staff and providers at Bibb Medical Center (BMC) in Centreville, Alabama delivered high quality patient care – but it did not include the comprehensive, team-based care that encompasses population health accountable care. The differences in population health with a team-based approach are not always immediately recognized. And yet sometimes, the differences are noticed quickly.

With new population health nurses trained and implementing new workflows, proactive patient outreach was underway. A call was placed to a patient who was due for her AWV. It was on that call that the patient’s son informed the nurse that it had become difficult to physically move her and get her out of the house. She had not been seen by a provider for six months due to COVID-19 risk factors and her new bedbound status. The patient has diet-controlled diabetes but her A1c had increased since her last lab results. Home health had been monitoring her coumadin levels but due to no decline or change in status they planned to stop the visits.

As the conversation progressed, the nurse learned about the anxiety and burdens the son was experiencing due to his mother’s declining mobility. In a short time, the BMC population health nurse took command and addressed the patient’s current status and social determinants that were resulting in compromised care. The population nurse’s action steps, shown below, not only resulted in improved patient care and health status but also the patient’s son was able to better manage his anxiety as his mother received more support and resources for his mother. The increased trust between the patient, family, and provider led to better outcomes.

BMC Population Health Nurse’s Action Steps:
  • The nurse informed the patient of the Provider House Call Program and enrolled her for services including routine visits, labs, ACP and depression screening assessments.
  • A licensed social worker made an in-home visit to identify and assist with social determinants. 
  • The AWV was completed in the patient’s home.
  • A PT/INR and A1c was obtained with the AWV and ordered by home provider to be obtained in the patient’s home in the future.
  • A Diabetic Education referral was made for services to be provided in the patient’s home. 
The patient is currently enrolled in a CCM program and reinforcement was provided on the importance of using these services and communicating about new needs and changes.

“The population health methodologies that we implemented at the beginning of the year provided us an opportunity to connect with more community health resources. Emphasizing a holistic approach to patient care is in everyone’s best interests and already we’re seeing positive results.”
Dawn Jones, RN
Bibb Medical Center
A Day in the Life of a Facesheet at Hendricks Regional Health
May 25, 2021
Hendricks Regional Health (Hendricks), a Magnet Certified Hospital serves suburban Indianapolis, Indiana. Since 2015, Hendricks has participated in a Caravan Health ACO. At Hendricks, bulk printing facesheets has become a daily part of the patient-provider experience. 
The medical facesheet is a summary of important information about a patient. It includes patient identification, medical history, medications, allergies, upcoming appointments, insurance status and other relevant information. At Caravan Health, clients use the facesheet to ensure all pertinent patient information is noted and combined in one easy-to-access resource. 
The daily journey of a medical facesheet
A facesheet is brought to life by a Hendricks office staff member two days prior to the patient’s visit. First thing in the morning, a staff member prints the facesheet based on a daily primary care schedule and places it in a dated folder specifically for the provider. Hendricks typically uses the HCC sheets, but some providers also use the quality sheets in addition to using the patient EMR. 
Prior to seeing the patient, the provider reviews the facesheet and local EMR to flag specific conditions and issues they are unaware of and/or need to discuss with the patient. The essential role of the facesheet is to help elevate awareness of chronic conditions, care history, and care gaps. Some patients have multiple chronic conditions and visits to different providers or even hospital admissions, keeping track of everything can be a challenge.
More than a printed piece of paper or the addition of a few diagnoses to a claim, the facesheet helps the providers monitor risk-adjustment and document anticipated changes with the patient. Without continued review and feedback, the provider’s job is compromised; the facesheet helps to connect the myriad of moving parts. The staff and providers at Hendricks include maintaining a problem list which further helps to increase the quality of patient care and preventive care. Problem list management and ongoing communication is a key point of focus for the Hendricks staff and providers.
As the provider uses pertinent information from the facesheet, discussion points and conditions are documented in the EMR and used to determine the treatment plan. Following the patient visit the facesheet, having done its job, is placed in the shred bin.
“Risk-adjustment is not intuitive. Our consistent review and feedback are all part of our plan and we make sure our workflows include a problem list and a system of checks and balances that has open, transparent communication. This is a work in progress for us and we’re realizing the benefits of facesheets and incorporating them into our best practice, team-based approach.”
Linda Gaul, RN, CCS
ACO Quality Operations Manager & Champion
Knox Community Hospital Understands that Quality Health Care Takes a Team
May 18, 2021

Located in Mt. Vernon, Ohio, Knox Community Hospital (Knox) serves its community with a wide range of services through their Joint Commission-accredited hospital. Knox has been with Caravan Health since 2016 and participates in the Collaborative ACO. 
A common occurrence when providers make the transition to value-based care is the sharing of patient success stories. Oftentimes these stories involve a social determinant or health literacy issue that was not previously identified with fee-for-service, traditional care approaches. The patient success stories offer pragmatic proof that team-based care helps to improve patient outcomes. Recently, the staff at Knox shared an example of team-based population health at work.
A 66-year old male with an impressive history of chronic illnesses including lymphocytic leukemia, atrial fibrillation, thrombocytopenia, hyperlipidemia, diverticulitis, bilateral hearing loss, sleep apnea, and obesity. The patient had recently been admitted to the hospital with COVID-related pneumonia and treated with broad spectrum antibiotics and a variety of other medications, convalescent plasma, and supplemental oxygen. 
Prior to making a call to the patient, the Knox TCM Navigator reviewed the patient’s discharge instructions and summary. The Navigator spotted a concern. The discharge summary included instructions to stop a cardiac medication due to infection. The Navigator followed up with a number of members of the collective care team and it was confirmed that the medication was to be halted, however, it was soon understood that the patient had continued to take the medication after being discharged.
Further collaboration and communication resulted in the stoppage of the medication due to heightened risk factors and the patient fully understood and complied. The patient was made aware that he was not to resume taking this cardiac medication until he received further instruction from his care team.
The experience not only resulted in the effective intervention of a patient who was continuing to take a medication that contraindicated his current health status, but it also encouraged the patient to express interest in more nurse-led support. The patient was referred to Knox’s Chronic Care Management Program.
“Our team-based approach is a foundation of the thoroughness of our patient care. With our enhanced communication we help patients not only gain access to the highest quality of service, but we also help to prevent them from falling through the cracks. Quality health care truly takes a team.”
Beth Tracy, RN
Knox Community Hospital
April 27, 2021
Helen Newberry Joy Hospital Increases HTN2 Measure to Lower Overall Hypertension Rates

Helen Newberry Joy Hospital (HNJH), has participated in a Caravan Health ACO since 2016 and serves a rural patient population in the northern-most reaches of Michigan. Aware that hypertension increases the risk of heart disease and stroke, two of the leading causes of death in the U.S., staff and providers at HNJH wanted to be more proactive with their preventive HTN2 measures. This measure helps screen for high blood pressure and the staff initiated a program to improve their preventive measures across their patient base. 
The hospital has reported a successful increase in preventive screenings. To learn more, we recently talked with Allison Blakely, Clinic Quality Supervisor at HNJH.
What was the catalyst behind the decision to place more emphasis on HTN2? 
“Hypertension is something that HNJH had focused on in 2019 and will continue to concentrate on this measure due to the high rate of hypertension diagnosis within our community. Understanding how hypertension is the starting point for many disease processes made this focus all the more important.”
What were some of the biggest challenges you experienced and how did you overcome them? 
“I believe two of the biggest challenges that HNJH faced was documentation of more than one blood pressure during a visit and also having patients return to have a blood pressure check at another time. To combat these issues we brought up case examples of how taking an additional blood pressure reading and documenting this in the chart helped to see whether the patient was well controlled and if further intervention was needed. Many examples brought up had a lower blood pressure reading during the visit that may not have been documented. If it had been we would see that the patient was on the correct therapy and did not need further interventions to help control their blood pressure. The second issue regarding getting patients back in for a return visit was tackled by making sure that patients were educated on what the return visit would consist of. The patient would be informed by staff that when they were to return for a blood pressure check it could be a nurse visit and something that would be quick and not billed. This improved numbers as well since patients knew what to expect and eliminated the assumption that it would be a long and costly visit.”
How have your patients responded? 
“Patient responses have improved! We will continue to track and encourage patients to return for blood pressure checks as needed.”
Can you share any data or outcome results? 
“Our patient return rates have improved.”
What advice do you have for other practices interested improving performance on this measure? 
“Explaining the process to staff and encouraging all staff to educate the patient on what is expected is one great way to start. Many times patients do not what to voice their concerns about time and money. With education, patients do not have to ask these questions and we can help reassure that this will not be a major disruption to their day or their bank account.”
Any patient success stories?
Andrea Marsh, Care Coordinator added, “We had one patient who did not want to come in due to the time they thought it would take to have a blood pressure check. The patient was a CCM patient and expressed to the Care Coordinator that they did not have the time to devote to coming back in for a visit. The Care Coordinator explained the process for a blood pressure check and that it would only take a short amount of time. This education provided by the Care Coordinator helped ease the patient’s concerns and increased their blood pressure follow ups.”

April 20, 2021
Sidney Health Center Utilizes Billers and Coders to Improve HCC Capture Rates

Sidney Health Center (SHC) serves a vast and rural community in Sidney, Montana. Having participated in a Caravan ACO since 2016, they are current members of the Caravan Health Collaborative. The staff has worked diligently to improve their HCC capture rates. At the beginning of 2020, SHC set a goal to achieve an 80% year end HCC capture rate. Despite the disruptions caused by the pandemic, by the end of 2020, SHC reached a rate of 77%. 

One of the first steps SHC took was to begin educating and training their billers and coders on HCC process improvement. This turned out to be the catalyst in improving their capture rates. The staff used Caravan’s EPIC alerts to identify gaps and opportunities. The billers and coders used Relias and Caravan’s portal and have now been trained on Coach facesheets to help further close HCC gaps.
When SHC set their goal of 80% HCC capture, the staff scheduled quarterly staff ‘Lunch & Learns’ to maintain an open level of communication and to review their progress. The SHC also worked closely with the providers and encouraged them to ensure they were coding to the highest specificity. Because the staff are committed to team-based care, it was only natural that the billers and coders communicated with providers whenever they saw an opportunity for a more precise level of coding.

One of the most recent process improvements involved including the billers and coders on the calls with the Caravan Health team calls, the Relias training, and in learning how to use the HCC facesheets. The billers and coders have become valued members of the clinical nursing team. SHC has continued the quarterly ‘Lunch & Learns’ and these have been well-received by both staff and providers. 
Sidney Health Center HCC Best Practice Results 
  1. Utilize EMR HCC alerts
  2. Billers & Coders are educated and trained on HCC
  3. Team-based approach progression toward collective goals
  4. Ranked in the top 20% for HCC recapture in their ACO
  5. End of 2020: 77% HCC capture
“Our team has learned that accurate HCC coding will lead to better patient outcomes. We’ve set ambitious goals for our HCC capture and based on the data and our engagement in team-based care, we are optimistic that we will achieve our goals. Improving the patient experience leads us to better patient outcomes and ultimately better financial outcomes.”
Beth Mindt, BSN, RN-BC
Sidney Health Center
April 13, 2021
Sullivan Community Hospital's Increase in Depression Screenings is Benefiting Their Community

Since 2016, Sullivan Community Hospital (SCH) has participated in Caravan’s Collaborative Pathways ACO. SCH serves a rural community in Indiana and in the past year placed more emphasis on depression screenings with the goal to intervene when necessary to either treat patients who are experiencing depression or prevent symptoms from escalating. 

SCH staff began increasing their rates of screening by incorporating their screening efforts with every Medicare AWV and CCM care plan. These efforts have led the staff to identify multiple patients in need of mental health services. The dedicated population health staff did not stop there. They have not only focused on their Medicare patients, but they have also expanded their PHQ-9 screenings clinic wide to all appropriate patients. Their goal is to ensure they are asking the right questions and initiating follow up for those patients in need. 

It’s ok to not be ok.

The enhanced efforts have paid off. The staff has been able to successfully identify multiple at-risk patients and have collaborated with their primary care clinics, their outpatient behavioral health program (Turning Leaf), and their local counseling centers. Every patient with a positive screen (>5) receives a follow up call from staff to probe further and identify specific patient needs for intervention. The staff are dedicated to working to eliminate the stigma attached to mental health and are consistent with their message that "it's ok not to be ok”. The staff meets patients where they are – meaning, they provide assurance that they are there to help and that judgements and concerns about what other people might think are neither reasonable nor welcome. 

This team-based approach focuses on holistic, whole person health care which doesn’t limit their care to medical needs but incorporates multiple areas that contribute to someone's overall wellness including, but not limited to, emotional, social, financial needs and intellectual capabilities. SCH patients understand that they have an advocate and someone they can call in a time of need. By asking the right questions, suggesting referrals, and offering follow up support the SCH staff is committed to the overall health of their community so that their patients are ultimately healthier, happier and safer. 

“With an emphasis placed on incorporating the PHQ-9 routinely, we have engaged our patients and our staff. Depression is on the rise across our country, and we are taking a proactive approach to intervene and treat whenever possible. It is incredibly important to ask patients how they are feeling. People are at risk of feeling more isolated than they ever have been so asking the right questions is imperative.”

Ashley Kilpatrick, RN 
Director of Care Coordination
Sullivan Community Hospital
April 6, 2021
First Care Uses Population Health to Improve the Patient Experience 

Population health methodologies are founded in nurse-led care with an emphasis on preventive measures. Value-based care results in improved patient outcomes by opening doors to better access to health, enhanced collaboration, and improved communication. First Care has participated in a Caravan ACO since 2016 and are currently active members in the Caravan Collaborative. First Care staff and providers have been trained in population health and had a successful transition to value-based care. 
In one recent example of a successful population health experience, First Care staff was working with a patient who had experienced three hospital admissions and four ED visits in a recent three-month period. The patient, a 64-year old woman with a history of CHF and COPD, has also battled alcoholism. She lives alone and relies on her son for transportation and other aspects of her care, but his job frequently requires him to be away for a week at a time. There are times when she is in need and he is not available.
Solving the social determinants of health for patients typically requires a variety of solutions, particularly when there are family members who are willing to help. It is important to include family members who want to be involved while making sure the patient’s best interests are the priority. 
Due to her son’s schedule, there were times the patient delayed care because he wasn’t available. This resulted in repeated calls to 911 and ED visits that could have otherwise been prevented. Following a hospital admission in November, during a COVID-19 surge, her son wanted to admit her to a long-term nursing facility. However, when the nurses followed up with the patient, they learned that she did not understand the nursing facility would be long-term and wanted to live at home.
The staff at First Care employed population health techniques and worked with both son and patient to find an outcome that was in her best interest. Despite his hesitancy, the son worked with the staff as he understood that her mental health and well-being was essential. 
Today, the patient is living at home with a strategic schedule of PT and OT and home health visits that are ensuring her needs are met. Her son was involved and found a metered alarm that reminds her to take her medication. He also fills her medication dispenser each week before he leaves for the workweek – this device unlocks each day at the time she needs to take the medication and sends her an alert. The new plans have been a success and today, she is working virtually with a counselor to address her alcohol dependency and she has also begun to exercise. Her physical and mental health is remarkedly improved. Both patient and her son are strong advocates for the First Care team and has recommended their primary care services and CCM to friends and family.
“Population health connects the dots in so many ways. Our focus on this patient resulted in improved chronic care management which resulted in improved patient outcomes. Our team-based approach is successful for our providers, our staff and our patients.”
Shelle Berg
First Care

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


NEWS: Signify Health Completes Acquisition of Caravan Health

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