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. 

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