Health care is constantly evolving – new programs, requirements, and regulations are the norm. Caravan Health’s experts understand this environment and bring their unique perspective to making the most of payment and delivery system reform. To learn more about how Caravan Health’s team works with ACOs, we asked our leaders and experts to weigh-in on what makes an ACO successful.

After two decades of guiding health organizations to success, Caravan Health’s Chief Program Officer, Jack Newsom, Sc.D., understands the challenges of constant change better than most. We spoke with him to find out how he’s applied this knowledge at Caravan Health and what advice he would give to both current and new ACOs. Register today for our third annual Accountable Care Symposium to hear more from Jack and other leaders in the field.

What are the top three ways Caravan Health’s approach helps ACOs “stay the course” during times of regulatory upheaval? 


First, our quality team has done a lot of work with the technology team to work more closely with clients. This collaboration allows us to do a better job of collecting data in a more consistent manner out of our client’s electronic health record [EHR] systems, which both reinforces the work the client is doing and gives them credit for their work. 

Second, we’re doing a better job through the quality improvement workshops of educating people around the ACO core concepts like annual wellness visits and chronic care management. We break things out by new clients versus established clients, and customize topics and content that meet people where they are, and we give them detailed actions they specifically can take to improve. 

And third, but not least, we help people understand opportunities for new programs and new codes, like behavioral health and remote patient monitoring.  

In these efforts, we help people do some of the basics, and do them really well, so they can take on some of the more complex or challenging populations in their communities in a prolonged, sustainable way.  


What are the most common barriers faced by ACOs? 


The main challenge, as is often the case with change in health care, is simply overcoming the inertia. You are asking people who are already overtaxed and working very, very hard to take on something else, something new, and do something different. You need to get their attention and have to help them understand the importance of it. It’s our job to do that and make it easy for them to make that change. 


How have advancements in data aggregation and analysis influenced the population health movement as a whole? 


One reason why ACOs may be more successful than, say, the managed service organizations from the mid-90s (which were conceptually very similar to what ACOs are today) is that the data and tech around it have changed dramatically. We can now look at patterns from not just claims data, but also from the EHR systems, and we can extract that to better understand what flu shot rates are in your practice versus mine versus someone else’s. That same capability then allows us to start to hold organizations accountable.  

Getting that data in the mid-90s, you’d find it was more than likely on paper. Now it’s electronic, and you can get it in a common form from different places and in different ways, overlaying data quickly and in new ways to find better approaches. We have made great strides with our quality and technology teams working together so that we can do exactly that.  

We’re positioned to identify the folks who are doing really well and the ones who are struggling and figure out why they are doing well or struggling and what they can learn from it or do about it.  


What is it about this that works best in the Caravan Health model? 


Our model here is really focused on execution and encouragement to actively be involved – for all levels of stakeholders. We really help them stay accountable for the results. A big part of the reason this works for us is that we use a scorecard, one we created, to keep everyone focused on goals. This helps us quickly find and work on any areas of weakness.   

At the same time, I don’t think we can give enough credit to the quality team and their ability to work with the integration analysts. Their work requires going into at least 75 EHR systems – and each practice puts that data in slightly different places in slightly different ways. We’ve developed real efficiencies because we found that when we focus on one system alone, to isolate it, we can see all the different ways a flu shot or mammogram gets coded there and where it goes in the system. Then we work with each client on that system to put that in the same place in the same way.  

Just like we work with the nurses – one-on-one giving them support through the process, giving bite-sized, digestible information and following-up with them – we apply that to the EHR team and the clients. We work with them step-by-step through a process we know inside and out, and build in accountability to get it done. It’s an education, and the change in the behavior afterwards only comes because now they understand why we are asking them to change. 


As we think about what’s facing ACOs of today and tomorrow, what advice would you give these organizations? 


Don’t treat data collection as a box to check off. There is a workflow of how data is input, stored, delivered, collected – and that needs attention and consistency. The same way we have a mantra in health care of “reduce variation to improve quality,” it has to be true for data, too. When facilities can achieve consistency with their data processes and analysis, like we [Caravan Health] do for our ACOs, they can see better outcomes. If we do things the same way every time, we can start to get a view of actual outcomes. Then, we can tweak that to get better and better outcomes as we go along. On the quality side, we’ve seen ACOs improve their quality scores 27 percent or more from one year to the next just from doing this.  

And keeping it in perspective, treating data input and management as a human process helps remind ourselves that, at the end of the day, it’s all about patient care. That’s the most important thing we can do for ourselves, our ACOs, and our ACO’s patients.  


Caravan Health helps physicians and hospitals work together to create, operate and manage successful population health programs that improve patient care, clinician satisfaction and financial performance. Out third annual Accountable Care Symposium is a great opportunity to learn directly from the experts. 

Register here.


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