Caravan Health is pleased to feature Memorial Medical Center from Southern Michigan Rural ACO as this month’s Client Spotlight. We are excited to share the outstanding achievements they have made over the last several months.


Front row left to right is: Derrick Longdo, Melissa Hemp, Paula Friedel, Wendy Crowe
Back row left to right is: Ryan Neville, Dr. Jennifer Schafer, Sarah Trunkel, Shannon Meddaugh, Sue Schultz, Sue Lewis, John Beauchamp
 

The Challenge

How was the implementation process of the initiatives and how long did it take?

It was a process that included forming a multidisciplinary team to address all issues in implementing this service. The group included clinic operations, I.T., Coding, Billing, HIS, providers, scheduling and Quality. We had many meetings over two months to get started, and we continued to meet every other week and now 2-3 times a month in various capacities.

What implementation challenges did you encounter and how did you overcome them?

  1. Getting providers to buy-in. We had several meetings with providers explaining the benefits of participating. In addition to emphasizing the quality care aspects, the financial benefits of participation were addressed. Provided education to providers and staff about the ACO (how it works) and why we should participate.
  2. Billing appropriately for these visits. We had many meetings with HIS/Coding/Billing and providers to review and explain how we can bill for these services. We worked with Caravan to assist us in the interpretation of the rules around charging these services.
  3. How to use EMR to aid us in seeing these patients and documenting their care and the Quality measures. We changed our EMR software just before participating in the ACO. This change was helpful and challenging at the same time. The new software better-accommodated participation in the ACO and Quality Measures but providers and staff had to learn both. The Athena software has been beneficial in meeting the requirements of participation.

Did you use any particular features/capabilities (e., Lightbeam)?

If so, of the ones you used the most, can you provide examples on ways you’re using these features/capabilities?

Our EMR (Athena) has been very helpful in assisting us to meet the requirements and Quality Measures of the program. Without the EMR it would have been much more difficult. Lightbeam has been beneficial in capturing charges related to AWV, CCM and TCM. Lightbeam was also critical in identifying our Medicare patient cohort and making it much easier to complete our annual GPRO reporting to Medicare.

What are some of your notable cases that these initiatives have presented?

One particular case doesn’t stand out above another, but we have seen improvement in certain patients health as a result of their CCM. There are patients out there who just need someone to monitor them on an ongoing basis to be at their best health. It’s about their quality of life during whatever time they have left.

Care Coordination Initiatives Q42016 1Q2017 2Q2017 Preliminary
AWV 11.3% 31.4% 45.6%
CCM 1.5% 3.0% 3.3%
TCM 7.2% 13.6% 18.6%
 (All Data Source: Lightbeam claims and EHR interface data)


The Results – see 2Q2017 in the table above

What improvements have you seen in services to your patients?

I think participation has raised awareness among the providers to be more proactive in keeping patients healthy rather than only treating them when they have a problem. The Quality Measures have spurred providers to address potential issues and have conversations with patients about preventing future problems.

What specific results have you seen since implementing these initiatives that support the data above?

Patients who have chronic problems are now being followed on an ongoing basis (CCM) and benefitting from that monitoring.  TCM care is keeping people out of the ED and reducing readmissions. AWVs are helping to identify patients who need preventative screening tests like colonoscopy, mammogram and ultimately catching any problems early.

Is there anyone that you would like to highlight at your facility that helped you achieve these goals?

This has truly been a team effort, but I do want to recognize Lisa Berres, our Care Coordinator, for her efforts in pushing the program to a higher level. I’d also like to thank or Clinic RNs, Melissa Hemp and Sharon Meddaugh and our ACO Medical Director, Dr. Shafer

What is your advice to others who might be having some difficulty?

Hire a care coordinator if you don’t have one already or assign someone to this job. It is critical that one person has the job oversight for the ACO and Quality Measures. Leadership and providers have to buy-in to the process and participation.  Get the right people at the table and educate everyone. It has to be a team approach. Communicate, communicate, communicate!

How did Caravan Health best support you?

Caravan has been a great help in getting us started and continuing to provide advice, consultation and answering the many questions we have.  They have also been great a continuing to push us to be better and assessing where we may need help and providing advice on how to improve.  We could not have done this without them.

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