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
Confluence
 



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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Deadline to join a Caravan-supported ACO is July 7. Speak with a Caravan expert to learn more.

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