Hospitals and physicians can’t afford to fail in population health management. It’s Caravan Health’s mission to ensure that doesn’t happen. Providers don’t set out to fail, but without clear direction or an experienced partner to guide the practice transformation process, challenges can lead to frustration, burnout, or unwelcome impact on care delivery or cost.  With a long list of care, reporting and compliance imperatives, extremely limited resources, siloed organizations, and an ever-changing reimbursement landscape, providers are faced with multi-faceted challenges as they work to deliver quality care and achieve reliable and sustainable financial results.
Success or failure of population health management is driven by two things: improving coordination of care and having the right data to drive actionable insight into your population health initiatives. Caravan’s model uses nurses as the catalyst for driving population health programs. Physicians lead the care team and employ nursing professionals to deliver preventive care. Together they track their team’s performance on core initiatives and quality outcomes. With this model in place, nurses can generate income up to $150k more per year. It also frees up physicians’ time, so they can focus more on diagnosis, treatment, planning, and management of complex cases.
Nicole BanisterNicole Banister, Caravan Health Vice President of Practice Transformation, recently shared her expert knowledge on the challenges and benefits of successful population health management. Banister leads the delivery team in their work with clients on Caravan’s core prevention and wellness initiatives.

How do you define population health?

Nicole Banister: Population health is a way to provide care that considers the health of an entire community and what's best for individual patients and their families. It involves improving the quality of care and also how patients are engaged in their care. Population health includes preventative care which saves money and lives.

What are the biggest areas of focus for population health programs?

Nicole Banister: It’s very important to continue identifying opportunities to improve care for patients in transition. This includes the transition between different physicians. For example, the exchange of care summaries between primary care and specialty care offices is paramount to ensure both physicians have up-to-date information when treating a patient to avoid duplication of tests and identify accurate diagnoses. Transitions also occur when patients move from hospital to post-acute care settings and back home. Coordination of care is key between these care teams and care settings to avoid medication errors in particular.  
Looking ahead the specifics of the workflows may change, but our clients will continue to be supported by a regional team that includes a regional vice president, clinical leader, improvement manager, and an interoperability specialist. This team stays current on changes to rules and regulations as well as best practices to make population health sustainable. Our clients are also supported by the entire Caravan Health organization, which includes our medical officers, subject matter experts, and other resources across the company.

What does this improved quality of care mean for the providers and for the patients?

Nicole Banister: Our ACO clients have achieved great success over the years since we began supporting large-scale collaborative efforts. One of the things that we do well at Caravan is provide data that is actionable and can inform the work for providers in their office. For example, understanding a practice wide, provider specific and patient specific trend in diabetes A1c levels can help to inform workflows and support changes that make a difference in patients’ lives.
We can help our providers and improve the quality of care of patients with diabetes in their practice by sharing this data that they in turn can act on to really move the needle in the types of care and services they provide to patients. Without measuring this information and having a systematic way to track some of these outcomes for a diabetes patient, it's hard to know where to start to really improve their care. Creating patient cohorts to track A1c values or to assign chronic care management services has helped our clients save time and improved the quality of care for patients.

How does an ACO help organizations improve the patient experience?

Nicole Banister: Much of what we do at Caravan, particularly around the training and the workflows for population health nurses, is focused on engaging the patient in their care. Some of our techniques for population health nurses include motivational interviewing, communication strategies, patient activation and reflective listening. These efforts help to engage the patient and ensure that their priorities, preferences, and choices for how they want to live their lives are incorporated into their care plan. Discussing what kinds of changes patients are willing to make is a huge step toward them becoming a partner in their health outcomes and improving their quality of life.

What are some of the biggest challenges that ACO participants face as they prepare for the transition to better coordinated care?

Nicole Banister: Better coordination of care takes a team. It can be difficult to move to a team-based care approach, especially if providers and staff have been operating in a one provider, one patient approach for many years. Coordination of care also involves increased communication with providers and facilities that may be identified as competitors and likely use different EHRs.  
One of our biggest strengths at Caravan is that we offer a regional delivery team that helps support practices in changing workflows. We work with hundreds of clients and can share tools and strategies that have worked well in similar environments. We can also evaluate billing approaches, IT tools, and staffing models, while simultaneously providing coaching and guidance on general change management principles. Sometimes having the information and the tools isn't enough. There's also an element around supporting culture change and getting the provider and staff buy-in on core initiatives. Caravan helps support culture change and promote buy-in, which helps our clients to achieve great results today and yields success and positive outcomes in the work that they do in the future.

To learn more about Caravan Health and how we can help you drive population health success, check out our recent webinar.


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