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. At the Virtual Accountable Care Symposium in December 2020, Ashley Kilpatrick, Director of Care Coordination at Sullivan County Community Hospital (SCCH), received the Caravan Health Population Health Nurse of the Year Pioneer Award.

Ashley plays an integral role in the health of her rural Indiana community and is dedicated to delivering the highest possible quality of population health. Having spent more than half of her 19-year nursing career working in her community, she finds the shift to population health refreshing. Acutely aware that social disparities and key determinants of health are often the root cause of many health issues, she is motivated to address those issues and has made concerted efforts to lead the initiative of team-based care at SCCH.
Ashley was surprised to receive the leadership award. Ashley and team focused on their goals and benchmarks while being additionally challenged, as most everyone, by the COVID-19 pandemic. When she realized she had won the prestigious award she commented, “I was shocked and I was speechless, which is rare for me!”
Just like population health takes a team, Ashley is backed by an incredible team who are committed to making their value-based care program successful. What started in 2016 as Ashley working alone has grown to a department of seven, including a population health nurse practitioner. “Time, research, patience and creative brain-storming has resulted in receiving this award”, added Ashley.
Indeed, Ashley and her team have worked closely with their Caravan team of experts. According to Ashley, “they have provided direction, support and availability. Our partnership has been wonderfully successful. I still learn something new every day! I know that I can always count on our Caravan team to answer any question that we might have.”
Ashley shared a recent patient success story that speaks to the value of team-based, coordinated care:

“I received a referral for a patient with COPD after discharge from the hospital. This patient lives alone and did not have a primary caregiver. The patient is dependent on oxygen, does not drive and due to disease process was unable to maintain their household environment, complete personal care without assistance, prep healthy meals and was experiencing frequent exacerbations of COPD. Upon admit to chronic care management (CCM) services, it was noted that they had been with a home health company for an extended period of time for therapy and nursing services. While nursing visits were beneficial, it wasn’t enough. Home Health wasn’t enough to meet the individual’s needs and they hadn’t addressed social issues. Through care coordination, we were able to help. Resource referrals were completed, and this patient now has home meal deliveries, attendant care to help with personal care, homemaker hours to help maintain their home, grocery shop and transport to medical appointments. I check in with this patient monthly to continue to ensure care needs are met. Since discharge from the hospital and admit to CCM services, this individual has not been back in the hospital and is doing great. Since starting services, we have been able to obtain additional referrals for mental health treatment (depression) and get them on traditional Medicaid. They have been able to go to the eye doctor (now under the eye doc’s care for treatment and monitoring of glaucoma) and visit with their dentist. This individual didn’t have secondary insurance coverage prior to her CCM referral.
SCCH is continuing to advance their initiatives and programs. They are actively focusing on post-acute care opportunities and have established several shared performance improvement goals with their primary care and specialty clinics with the goal to increase their depression screenings and capture more accurate HCC codes.
Caravan Health is committed to helping clients make the transition to population health models of care by providing cutting-edge tools such as Caravan Coach, the ACO tool that makes data and information readily accessible, and resources including the new 340B software that helps safety net providers benefit from the drug discount program.

Caravan Health congratulations Ashley Kirkpatrick and the dedicated team of staff and providers at SCCH. To learn more about Caravan Health's latest 340B software, join Lynn Barr, Founder and Executive Chairwoman on May 18. 

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