Caravan Health’s Population Health Pioneer Awards highlight their ACO participants who have incorporated innovative approaches to value-based care and demonstrated a commitment to diversity, equity, and inclusion either in the workplace or the communities they serve.

Carle Health, part of the Stratum Med ACO, serves a broad base of rural patients in the Champaign/Urbana area and received Caravan’s Partnership Manager Award. We recently talked with Kristin Kohl, the ACO Director of Clinical Improvement, to learn more.
 
What did winning the Partnership Manager Pioneer Award mean to you and Carle Health?
“Receiving this award solidified that the work of starting up a new ACO was both recognized and creating an impact on our patients.”
 
Did the award come as a surprise?
“Yes, we had only been part of the Caravan Health Stratum Med ACO since July of 2019. I was new to this role as of May 2019. Our leadership team had joked around during the 2019 ACO Annual Symposium that it would be great to be on that stage winning an award soon. We had no idea that would actually happen 16 months into our ACO journey.”
 
Did you/your staff set a goal to win a Pioneer Award?
“No, we were still putting all of the pieces together and working to ensure success in the overall program.”
 
Please describe the ‘behind the scenes’ work that went into winning the award.
“Close partnership with Caravan Heath on establishing processes for annual wellness visits, appropriate HCC Coding, and chronic care management was key. As this was a new program for Carle Health, all population health RN and CMA staff had to be hired and trained on brand new processes. There was a lot of process development, training, and then tweaking of processes initially until we found what worked best for our team, patients and providers.”
 
What has been your experience participating in the Caravan Health ACO?
“Kerry Quinn is my partnership manager on the Caravan Health side. I could not ask to be working with a better leader and mentor. Every employee who I have encountered and worked with at Caravan Health has been prompt in responding and goes the extra mile to assist us with our needs.”
 
What has surprised you about population health and/or value-based care?
“The overall buy-in and engagement of not only the providers, but also the patients. There was not any resistance as we had already developed solid team-based care initiatives. It almost felt that this was the next normal step for Carle Health.”
 
Where is your facility headed? Do you have new benchmarks, initiatives, etc?
“We will continue to grow not only through our ACO program, but also through multiple additional population health services. We are focusing on integrating additional resources into the clinics such as pharmacists, health coaches, case managers, behaviorists, dieticians, and multiple others. These additional resources will focus specifically on the at-risk patient populations at Carle Health.”
 
Is there anything else you would like to share?
“I will never forget one our very first ACO AWV patients. I was working with the assigned ACO Population Health nurse when this patient came in for her AWV. We had instructed her to bring all medications and durable medical equipment to the office for us to ensure accuracy. The patient brought a blood glucose monitoring system with her. She informed us that the glucose meter had not been working for quite some time, but that she was not concerned because her provider told her that her diabetes looked good and to continue what she was doing at home. The provider did not know the patient was not checking her blood sugars routinely and the patient did not disclose that, as she knew she could not afford a new meter. The patient admitted that she was not trying to be non-compliant but had financial difficulties. I was able to troubleshoot the meter for her and saw that a new battery was placed in the device upside down. When I placed the battery in correctly, the meter worked again. I was able to label the meter with easy-to-see instructions. The patient was very thankful that her meter had been fixed without an additional cost to her and agreed to start checking her blood sugars.”
 
This was literally one of our first 10 patients. This proved to me how important and integral this program was going to be for our patient population. Having a nurse complete the wellness visit and taking extra time with the patient face-to-face, we were able to problem solve for the patient and get her back on the right track with her health care.”
 
Watch the 2020 Population Health Pioneer Awards presentation and hear more from Kristin Kohl (previously Kristin Ford)


To learn more about Caravan Health visit www.caravanhealth.com 

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