Caravan Health Vice President of Customer Success Greg Paris hosted a webinar highlighting the five habits of successful ACOs. Greg has been with Caravan for four years and knows all the tips and tricks of great ACOs. As VP of Customer Success, he leads regional teams, including overseeing regional vice presidents spread out all over the country. He talks to our partner providers every day, from those that are high-performing to those that are still finding their way in accountable care. His experience as a former small hospital CEO lets him know how hard, but rewarding, this work can be.   

CMS has made it clear that value-based care soon won’t be optional for providers in Medicare. Even our rural partners will have to get into risk before long. CMS is planning to announce a new rural model later this year. From everything we hear, it will be based on ACO principles and include a path to risk. All providers simply must learn how to thrive in this new environment and these five tips from Greg can get you there.  

Habit 1: Pool Lives to Mitigate Risk 

Some ACOs put in all the hard work of practice transformation and still find inconsistent results that could leave them on the hook for writing a check to CMS. The key to overcoming this uncertainty is growing your ACO with enough scale to overcome statistical variation. ACOs with fewer than 20,000 lives can have random savings and losses of up to 20 percent. No ACO can take those chances.  

Caravan Health has seen this firsthand. Even an especially bad flu season can increase costs unexpectedly and throw off results, through no fault of the provider. More lives will protect everyone against random variation. That’s why Caravan pioneered the collaborative ACO of at least 100,000 lives. In fact, we launched the country’s largest ACO earlier this year with more than 225,000 Medicare lives.   

Habit 2. Gain Physician Buy-In and Connect the Organization.  

Successful practice transformation starts with building a strong primary care team. In some models, physicians are expected to take on any extra work of transforming primary care. This simply won’t work and could actually increase the already tremendous burnout that many physicians face. Everyone in the organization should contribute at the top of their ability. Team-based care spreads the work to those who can most effectively get it done while minimizing burnout.  

In the Caravan Health model, population health nurses take the lead on care delivery with excellent financial results. Chronic care management services can bring in $90 per month per patient, while annual wellness visits can earn a practice $118 per year per patient in new revenue. Both of these services are critical to making individualized care plans that can prevent many more costly services down the line. Investment in population health nurses more than pays for itself.  

This slide shows how Knox Hospital in Mount Vernon Ohio employed population health nurses to increase from 7 AWVs in a year to over 3700 annually in just three years.  


Habit 3. Adopt an Effective Change Management Process.  

Primary care transformation involves changing the way providers do business. Different parts of the organization need to seamlessly work together to achieve care quality and financial goals. Tampa General Hospital was able to successfully transform and save $350,000 in the first six months.  


Greg talked about the “Phases of Competency and Change” as one way of understanding this transition. The provider evolves from not knowing what needs to be done - unconsciously unskilled – to being able to get things done correctly without even thinking about it. – unconsciously skilled. In a successful change management process, all members of the care team are at this top level.  


Habit 4. Control Costs and Pinpoint Gaps in Care Through Actionable Analytics

Caravan Health partners use Caravan Compass, a powerful management and analytics tool, to better understand data such as utilization and expenses. In addition to this platform, Caravan data analysts offer support help understand any trouble spots.   

Caravan Compass produces data, down to the practice and provider level, that appears in an easy-to-read scorecard to keep everyone focused on the same goals. The scorecard also easily identifies areas for improvement. Providers can easily track specific metrics aligned with goals such as increasing the AWV rate or participation in cohort meetings.  

Habit 5. Remain Disciplined and Hold Everyone Accountable 

A data-focused approach keeps providers accountable to each other in the ACO. If the data show that a provider is struggling to keep up, Caravan has a remediation process to get all participants up to expectations. Remediation involves regular meetings, check-ins, and a commitment to measurable improvement. While it may not always be pleasant, it gets results. In our experience, almost all practices improve significantly and graduate from remediation on time.  

Providers need to know that value-based care is coming. Joining an ACO includes incentives, like shared savings, that make it worthwhile to jump in sooner rather than later. Caravan Health is so confident in our model that we will take on 75% of your risk. 

Hear more from Greg’s webinar

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