“We are stronger working together” – Caravan Health client 

2020 has been a year of challenges for everyone and health care providers have been among the hardest hit by the COVID-19 pandemic. As we begin to look ahead to the new year, we decided to stop and take a look back at what we’ve come through together. How have we changed? What surprised us? What did we learn? We asked our clients and below are the collective responses. 

Few, if anyone, would have predicted 2020 to be the year of the public health emergency. As you look back at the start and progression of the COVID-19 pandemic, what do you believe was your facility’s biggest challenge? 

  • Strategizing ways to keep patients healthy & able to access services 

  • Recovering revenue through telehealth visits 

  • Learning how to use telehealth & teaching it to patients 

  • Keeping up with changing guidelines & regulations 

Many providers had doors of opportunity close this year – what do you believe your organization lost due to the pandemic? 

  • The ability to impact patients by educating them on the importance of preventive care 

  • Momentum on population health initiatives including CCM & AWV 

  • The ability to close care gaps  

  • Continuity of care with patients afraid to come in for screenings  

Turmoil and challenge often result in growth and success. What successful experience surprised you about your team, facility, patients, and/or community this past year? 

  • The ability to quickly adopt & implement telehealth services & remote monitoring 

  • The trust patients have in their providers 

  • Camaraderie & support of communities with resources, volunteers, donations, etc.  

  • The ability to work with community leaders to help inform patients & residents 

  • The dedication of employees, providers, clinicians, staff, admin, patients & community leaders 

As we close the door on 2020, what will be your biggest takeaway from the year? 

  • The importance of team-based care & the impact it can have on communities 

  • The importance of being flexible to the ebbs & flows of changing guidelines 

  • Appreciating organizations who value their employees & put their safety first 

  • Health care entities can do anything when the right supports are provided  

  • Regulations do not have to be barriers 

  • Concern for continued COVID-fatigue in 2021 

Reid Health Implements Successful Behavioral Health Integration Plan 

Serving the extended communities of Richmond, IN, Reid Health (Reid), has been with Caravan Health since 2015, and is currently part of the Crouse/Pathways Collaborative ACO. Reid’s Behavioral Health Integration (BHI) program has been recognized for its success and patient engagement. Britany Swallow serves as Reid’s Behavioral Health Coordinator, and with April Coffin, Director of Outpatient Behavioral Health, together they have collaborated to ensure patients have access to everything they need while they work with staff to achieve their goals. In Reid’s case, seven may be their lucky number. 

7 Keys to Reid’s BHI Success 

  1. Patient Identification and Outreach: Each week, Britany creates patient eligibility lists and provides them to the practices for potential enrollment in the BHI program. She visits and communicates with each site on a rotating basis to establish relationships with their care coordinators and providers. Provider referrals are one of the most successful routes of patient enrollment.  

  1. Overcoming Contract Disputes: Britany established a relationship with coding and billing departments and ensured time tracking was completed accurately. This has helped make the billing process smoother resulting in more admin buy-in and leveraging additional resources for patients with financial hardships. 

  1. Marketing & Advertising:  A Reid BHI website, brochures with care coordinators information and pictures, and sharing patient testimonials has helped with patient buy-in and referrals. 

  1. Enrollment process:  If a patient is seen by the provider, and the provider referred them to the BHI program, they bring in Britany to meet with the patient for a warm hand-off which includes an introduction, consent, and an overview of the program. Similar to their CCM program, she uses a complexity grid to assess how frequently she meets with the patient and has scheduled acuity reviews. If the patient scores 0-5 they meet every month, a score of 5-10 they meet every two weeks, and 10 or more – they meet once a week. 

  1. Care Plans: Britany documents each visit and has the provider signs off on the note in the EHR. They also have a standard follow-up protocol. If they are unable to reach a patient after three attempts, a letter is sent to the patient stating that Britany has been trying to reach them and asks the patient to contact Reid Health.   

  1. Billing: Britany tracks time with each patient, collects out of pocket payments (what? copays? payment) and bills for her services each month. Having a centralized person in place has help to standardize the billing process along with the documentation in their EMR.  

  1. Graduation Process: Britany uses the GAD-7 and the PHQ-9 to check progress over time for patients with depression each month to every three months. Interacting regularly with the behavioral health coordinator has resulted in significant improvements in PHQ-9 scores. These tools also help to identify clients who may be able to graduate from the BHI Program. 

“Our behavioral health coordination program is absolutely outstanding. As a provider, it has enabled me to address my patient’s mental health in a more comprehensive manner. Every patient who has made contact with this program has had a greatly improved mental health outcome. This community is blessed to have this program.” 

JoAnna Reisert, FNP-C 
Reid Health 

Chambers Health Improves Patient Outcomes by Focusing on HCC Coding 

Chambers Health runs a critical access hospital and two FQHC’s in Anahuac and Belview, Texas. With the acknowledgement of the constant and unpredictable change in health care and the goal to improve patient care, staff and providers set out to focus on the patient as a whole person – not just symptoms or one area of care. 

As comprehensive patient outcomes became a priority, they analyzed key performance indicators, reviewed Caravan Compass reports, and worked closely with their Caravan partners to identify gaps in care. It became apparent there was potential to place more emphasis on HCC coding to assuage gaps between medical teams and coders and further embrace value-based care. As the Chambers staff continued to work closely with Caravan Health, they were able to successfully transition to a level of care that placed improved HCC coding at the top of their list of patient care priorities.  

Their successful strategies included: 

  • Taking the FQHC approach of comprehensive patient care and treating the whole patient rather than one area of symptomology. 

  • Gaining commitment from leadership with transparent and open communication to pursue HCC coding improvements. 

  • Utilizing an external audit for objective analyses that would be fair to all providers. 

  • One-on-one provider education based on the results of their specific audit. 

  • Using HCC face sheets for AWVs to ensure diagnosis reconciliation and preventive screenings. 

The results of their efforts has been profound. Patient outcomes have improved, staff and providers are not only more informed about the opportunities of HCC coding, but have also identified cancer in patients early on, communication between primary care providers and specialists has improved, and the previously identified gaps in care have substantially narrowed.  

Today, the collective Chambers team has made a new commitment to pursuing patient centered care and are working to receive the Patient Centered Medical Home designation through NCQA, with plans to align those goals with their ACO goals. They are continuing to use Caravan Compass to identify highest costs and outliers within their referral system, discussing the use of crosswalks to streamline processes, and are on track to have a PCMH designation by this time next year. 

“We’ve made it a priority to improve patient care. We feel like it’s not only an improvement for them and their care and their future wellbeing, but it’s also an improvement for us to show that we’re able to work comprehensively and try to address their health care needs.” 

Nellie Lunsford 
Director of Compliance 

Tri-State Memorial Hospital Uses Quality Data to Build Successful Chronic Care Management Program 

Tri-State Memorial Hospital (TSMH) is a critical access hospital with primary care and specialty clinics serving residents in Clarkson, Washington and Lewiston, Idaho. In 2018, physicians and staff worked with Caravan Health to build a chronic care management (CCM) program. With new goals to increase preventive services, improve disease management and better engage patients they recruited Nicole Louchart, RN, to further develop the program. She joined TSMH and brought with her a unique approach to enhancing the program. 

Nicole started by completing Caravan’s Health Coaching Program and Population Health Orientation to develop her skillsets. She also relocated her workspace to be in close proximity to the providers who served Medicare beneficiaries. In hindsight, it was the seemingly simple change in location that helped her establish the essential relationships needed to enhance the program. By working in the same area with the providers who treated the patients who would benefit the most by CCM, Nicole increased transparency and communication and has led TSMH to success. Today, TSMH’s CCM program emphasizes communication between patient and collective care teams.  

Five key steps that helped TSMH enhance their CCM program: 

  1. Involving the entire team with consistent meetings helps everyone state on top of policy changes. 

  1. Billing staff & accurate coding are essential, including follow-through on secondary insurances. 

  1. Reviewing data and goals each quarter ensures that patients and/or opportunities do not fall through the cracks. 

  1. Identifying & engaging patients by cohorts help staff maintain continuity of care. 

  1. Communicating with providers, staff, and patients help with introductions and enrollments which sets the foundation for success. 

“Sometimes people will say, ‘Oh, they’re not compliant,’ and write them off. Well, in chronic care management, those are the patients you’re looking for. It’s not that people don’t want to be compliant, they can’t. They might be choosing between buying medications and paying rent.” 

Nicole Louchart, RN 
Tri-State Memorial Hospital 

Helen Newberry Joy Hospital Nurses Impact Social Determinants of Health & Improve Care 

Population Health nurses at Helen Newberry Joy Hospital (HNJH) serve a rural community in the eastern Upper Peninsula of Michigan. HNJH has been part of Caravan’s collaborative ACO since 2016. In addition to delivering value-based care, the nurses are dedicated to taking advantage of continuing education and training opportunities that help to enhance their skills. 

Following the first week of a Caravan Health PHN training on communication styles, Population Health Nurse Andrea Marsh, had the opportunity to use her new skills in a challenging patient situation. She had been working with an underserved, disadvantaged family with a Chronic Care Management (CCM) patient who lived with some complex medical challenges. Throughout their entire care history, it was assumed the daughter was the most competent person to receive and disseminate written instructions. While the daughter was amenable, Andrea noted inconsistent follow through. In time, with more conversations with the extended family using her new communication skills, Andrea discovered that the family spokesperson could not read. 

Today, the nursing staff intervenes as necessary to ensure that whenever written instructions are provided, they invest more time talking with the daughter, using visual aids with symbols and drawings to ensure she understands. The nurses are continuing their collaborative efforts with the family to ensure that care, instructions, and communication works for them. Communication has been significantly improved and customized which has resulted in better care for the entire family’s health and well-being. 

“Population health relies on good communication skills. I wanted to enhance my patient care and to improve our team dynamic with higher quality skills. We are continuing our focus on efficiency and team-based care and with each new experience our team learns and shares best practice techniques.” 

Allison Blakely, RN 
Helen Newberry Joy Hospital 

Coal Country Community Health Center Focuses on the Patient with ACP 

Based in Beulah, North Dakota, Coal Country Community Health Center (CCCHC), operates four FQHCs and are active members of Caravan’s Collaborative ACO. CCCHC has set themselves apart by far exceeding an ambitious goal to provide Advance Care Planning (ACP) to 15% of their Medicare patients. Currently, more than 30% of CCCHC’s Medicare patients receive ACP.  

CCCHC staff established workflows and a care coordination committee was established to ensure the continuity of their messaging and services. The committee brought providers and clinics together which has led to nurses and social workers becoming certified in, ‘Honoring Choices’, to help promote more meaningful conversations where patients can express their values and wishes for their end-of-life care. Staff from the local critical access hospital, long-term care facility, ambulance services, and the public health unit have been trained to guide these conversations. Today, 75% of nurses and social workers have been certified and behavioral health care coordinators are currently being trained. 

As staff worked to enhance their focus on patients, they also identified other essential components that helped embolden the strength of their ACP program including: 

  • Accurate coding & billing ensures proper documentation and makes transitions to new EMRs and other technologies more efficient 

  • Follow-up & scheduling helps to keep conversations open and fluid between provider, patient, and family and loved ones. 

  • Understanding that AWVs & ACPs visits are not separately reimbursable when performed the same day meant that CCCHC opted to forgo a second visit requirement in order to see the patient and have the ACP conversation. 

  • Monthly meetings provide an opportunity to discuss obstacles, help to engage providers, and ensure that the entire team, including billers and coders, care coordinators, nurses, behavioral health providers and C-suite executives are included in the over-arching plan. 

“When you look at how nursing has evolved, it's really a whole person approach and Advance Care Planning is a huge component. ACP is what's right for the patient. It's what's right for our care teams—being able to have the conversation prior to it becoming a critical situation.” 

Chastity Dolbec, RN 
Coal Country Community Health Center 


Hancock Regional Hospital Highlights the Importance of Preventive Care 

Since 2015, Hancock Regional Hospital (Hancock), has participated in the Suburban Health Network ACO. Hospital providers and staff are well-versed in population health models of care and when the COVID-19 pandemic hit the nation the Indiana-based, health care facility focused on a core component of value-based care: preventive health care and proactive screenings.  

Population health care emphasizes the importance of screenings in order to improve patient health. Population health nurses at Hancock stayed alert to not only their high-risk patients, but also to patients who may not present as high-risk but due to anxiety or apprehension were at increased risk for depression or other behavioral health illnesses. 

As health care delivery was disrupted across the nation, Hancock nurses remained steadfast to preventive screenings. With concern for the ripple effect of anxiety, depression and isolation due to the pandemic restrictions, nurses proactively reached out to their patients with questions to facilitate open conversations.  

One result of a proactive outreach call had an almost immediate effect on a house-bound patient. The patient’s heightened fears about catching the virus resulted in her wearing a face covering inside her house. Despite it being summertime in Indiana, she was afraid to open her windows and the patient had grown increasingly isolated and hesitant to leave her home. Nurses were not only concerned for her mental well-being but also for her decreasing supply of food, medications, and other essentials. 

On that call a population health nurse took the time to listen to the patient as she voiced her concerns and then explained specific steps for her to take to ensure that she was using best practices while not succumbing further to depression and isolation. In a follow up call a few days later, the patient’s quality of life had improved, her fears had been alleviated, and while she was still concerned about the virus – her response fell into the normative range.  

“We know that preventive care and screenings are important and our focus on these have been particularly useful for patients experiencing depression and anxiety during the public health emergency. It’s always better to plan ahead and prevent a potential event than to have a reactive approach. Our proactive methods have helped improve outpatient care.” 

Tish Morris, RN 
Hancock Regional Hospital 

Carteret Medical Group Uses AWV to Solve Social Determinants of Health for Patient in Need 

Carteret Medical Group (CMG) has been an active member of the Myriad Health Alliance since 2018. At CMG, population health nurses routinely use the Annual Wellness Visit (AWV) to screen patients and encourage open conversations about their health care and access to health.  

When a patient with a history of Type 2 Diabetes presented with comorbidities, Carteret nurses explained, and recommended, Chronic Care Management (CCM) and the patient agreed to be enrolled. Nurses quickly identified concerning factors including the patient’s inability to pay for an expensive new-generation medication to treat her diabetes. A consult was arranged with an Endocrinologist who prescribed an equally-effective but more affordable medication and the patient began taking the medication immediately. 

In addition, the patient had an above-the-knee amputation and had relied on her long-standing roommate for groceries and help with errands and transportation. Her roommate, however, had recently died unexpectedly and the patient’s access to groceries and other necessities was severely compromised.  

Relying on population health strategies, nursing staff spent time with the patient, helped to educate her on her health care needs and also helped to resolve some socioeconomic needs that had begun to affect her health. The patient learned how to read food labels, prepare healthy meals, and identify portion size. The patient became motivated to learn and help herself and expressed goals to lose weight, eat better, and lower her HbA1c. 

Twelve months later, the patient was active in the CCM program and requested to continue in CCM. She maintained consistent communication with her health care providers and was continuing to take advantage of community resources to help her with transportation and food delivery. She is now scheduled to receive 12 hours of in-home assistance each week. Additionally, the patient has lost more than 20 pounds and her HbA1c has decreased from 6.6 to 4.9. She continues to be motivated and is an active participant in her health care. 

“The population health nurse training modules from Caravan stressed the importance of addressing all the aspects of a patient’s life that can impact their ability to manage their disease. The patient recently had a positive biopsy result at the site of her original cancer. She will be undergoing surgery and further treatment. The patient will need continued emotional support as she goes through this process.” 

Anne Kypraios, RN 
Carteret Medical Group 

Memorial Community Health Joins ACO and Focuses on Preventive Care 

Memorial Community Health Inc., (MCH), has served residents of rural counties in eastern Nebraska for more than 60 years. In 2016, MCH joined Caravan’s Collaborative ACO with the goals to improve the quality of patient care and increase revenue for the hospital. By working closely with Caravan experts who provided support, education and resources MCH staff established new population health workflows with emphasis on the Annual Wellness Visit (AWV). 

As MCH embraced population health, more emphasis was placed on preventive care and population health nurses Lisa Friesen and Cindy McDaniels worked with staff to schedule AWVs. Their process evolved to perform AWVs in conjunction with provider visits for two reasons, (1) to prevent their patients from coming in for an extra visit in their rural area and, (2) to encourage patient participation and engagement. Staff and providers prefer this back-to-back visit to ensure that patient problems are addressed based on the results of the screenings.  

Once example of this successful model involved a patient with a history of tobacco use who typically did not see a doctor unless he felt ill. Encouraged by nurses to have an AWV with an upcoming checkup, the patient agreed to his first-ever AWV. During the screenings, the patient agreed to an AAA screening and a chest x-ray due to his advanced age and smoking history. Staff performed those tests while he was on site for his appointments.  

The AAA screening was positive for an 8 cm aortic aneurism and nurses were quick to refer him to a vascular surgeon - the repair was scheduled within a week of the screening.  A low dose chest CT was also completed which showed a small nodule which has been addressed and is now under the watchful eyes of a pulmonologist. 

Today, the patient is doing well and recovering from his AAA repair.  He plans to return to work once his post-op restrictions are lifted. He has also agreed to have a colonoscopy once he has fully recovered. 

“We set a goal to increase our Annual Wellness Visits and place more emphasis on screenings. This has improved our ability to intervene when necessary and help to prevent more serious situations. Our patients have responded well, and we are continuing to add more AWVs to our schedule.” 

Lisa Friesen, RN 
Memorial Community Health, Inc. 

Tampa General Hospital Improves Patient Outcomes with Population Health

In 2019, Tampa General Hospital (TGH) made the decision to join the Caravan Health Collaborative ACO. From all accounts, the Florida-based hospital has not looked back. The enhanced focus on patient care using population health methodologies has made a significant difference in overall outcomes in a short amount of time.  

One recent example highlights the benefit of the improved patient-provider relationship. A population health nurse discovered that a patient with diabetes had stopped taking her meds due to the high cost of the prescription. In a routine nurse-led screening, the patient opened up to the nurse and explained that she knew she needed to take her meds but there were times that she couldn’t afford to refill the script. 

The nurse went to work to solve the obstacle and create opportunities for the patient. She spent time with the patient and learned about her lifestyle and began a series of conversations about the importance of healthy living, provided eating tips including healthy snacks and meals, and an found an affordable YMCA membership to encourage exercise. Providers worked with the local pharmacy and safely changed her prescription to a less expensive option.  

The patient became actively engaged and encouraged by the affordable prescription, took more ownership and began following the advice of her care team. Patient records now show a patient with diabetes who is committed to taking her meds and has adopted a healthier lifestyle.  

The numbers speak for themselves: her cholesterol numbers dropped from 144 to 127, triglycerides dropped from 148 to 116 and today, her liver functions are in the normal range. An AIC goal of 7% was set and has been achieved. 

“With population health, we’re able to dive deeper with patients and get to know them on an all-new level. The extra time spent with them is making a difference. We’re improving our outcomes and our patients are taking ownership of their own health. It’s a win-win.” 

Adrienne Holmes BSN, RN 
Tampa General Hospital 

Lost Rivers Population Health Nurse Empowers Patients to Improve Outcomes

Lost Rivers Medical Center (LRMC) is a Critical Access Hospital that provides primary and preventive health care and emergency services to the surrounding communities of rural Argo, Idaho. LRMC is new to accountable care having joined the Eastern Idaho Care Partners ACO this year. The hospital has embraced the nurse-led model of population health and patient outcomes have already improved.

Robin Mangan, LPN, emphasizes patient care and works closely with those who are willing and able to take on a more proactive role in their health. As Robin spent time getting to know a patient with higher-than-acceptable blood pressure, she was prepared to discuss a newly prescribed medication along with the benefits of diet and exercise. She was concerned at the fluctuations in the pressures and taught the patient how to use a loaner cuff to measure his pressures from home. She noticed, however, that as they practiced with the cuff, his pressure was close to normal. Rather than start the meds, Robin consulted with the provider and they opted to delay the prescription for concern that his pressures could go too low. She sent her patient home with the loaner cuff to use during a trial phase and suggestions for improving his diet and exercise.

Within a short period of time the patient discovered his pressure was only high when he was anxious and feeling stressed. As he became more engaged in his health, he learned that if he took care of himself when stressed and purposefully did something to relax, he could manage his blood pressure and keep it under control without medication. Ultimately, the patient achieved target blood pressure values and did not require medication.

Meanwhile, a patient with multiple chronic conditions and a learning deficit was feeling fearful of a recent Type 2 Diabetes diagnosis. Robin taught her patient how to use a glucometer and spent time explaining how to control his diet and maintain his blood glucose levels to avoid the fluctuations of highs and lows. She explained that he didn’t need to check his levels six times a day as he was doing out of fear. And, she taught him how to prepare for days when he would be ill with a just-in-case ‘sick-day kit’.

Today, the patient is actively engaged in his health, has confidence checking his blood glucose, and has learned to manage his diabetes. This summer he is healthy enough to have a lawn-care job. This type of patient care exemplifies the benefits of population health – care that improves patient outcomes and, in some cases, avoids unnecessary prescription medication.
"As a PHN, it is very gratifying to see my patients take what they have learned and act upon it to manage their chronic illnesses and improve their quality of life. It especially makes me happy to see the joy patients have when they realize they have the control and the disease needn't control them." 
Robin Mangan, LPN
Care Manager
Lost Rivers Medical Center

Confluence Health Joins ACO & Successfully Transitions to a Nurse-led Approach to Care


Confluence Health (Confluence), located in Wenatchee, Washington, is the major medical provider between Seattle and Spokane. More than 300 physicians and 150 advance practice clinicians serve patients in the integrated health system that includes two hospitals and more than 40 medical specialties. Confluence joined Caravan’s Stratum Med ACO in the summer of 2019.

Patient care had always been a top priority with staff, however, prior to joining the ACO they did not have standard workflows in place to facilitate communication between primary care departments. The Caravan team worked with Confluence staff to restructure the case management team processes. The new workflows enabled the 10 case managers to complete AWV intakes for the 130+ primary care providers in 14 different locations. This gives every patient the opportunity to receive case management services including support for the social determinants of health.

Helping patients “get through the medical maze.”
Corinne Loyd, Confluence TCM Nurse Case Manager, recently shared one case – among many – where the restructured case management made a difference in a patient’s life. When Corinne contacted the terminally ill patient for TCM, she learned how one particular nurse, Bernie Stanfield, helped him and his wife as he described it, “get through the medical maze. Corrine explained that the patient said he couldn’t imagine what people do “if they don’t have a Bernie,” as he explained the stress of navigating end-of-life decisions with multiple doctors on his care team.
Confluence’s Chronic Care Management program was just beginning to be implemented when COVID-19 began to affect their region. Despite redeploying staff to work with COVID-19 assignments and placing a hold on non-essential office visits, they have demonstrated measurable care management program growth based on Caravan’s guidance and the commitment to a nurse-led, team-based approach. The staff continue to hear positive feedback from patients as they continue to their expansion of population health care.
“We all have the patient as the center of our focus and through the support of each other, we are able to provide excellence in patient care. This patient’s sincere appreciation of Bernie was so heartfelt and moving, and I was so moved by his descriptions of the impact she had on his life; I wish I could have recorded our conversation.  She really was his angel on earth.”
Corinne Loyd, RN, CCM, CBN
TCM Nurse Case Manager
“What I did for this gentleman was mostly behavioral health.  Yes, I talked to him and his family about advanced care planning, housing options and physical needs but the majority of my ‘work’ was preparing him for transitions. We discussed her needs and his spirituality and everything in between.”
Bernie Stanfield, RN, BSN
CCM Nurse Case Manager

Population Health is Part of the Culture at McKenzie Health

Since 2014, McKenzie Health System (McKenzie), in Sandusky, Michigan, has participated in a Caravan Health ACO. Interested in adopting a wellness model of care, hospital administrators encouraged the transition to value-based care in order to identify illnesses sooner, apply interventions, and improve patient outcomes. The patient-centered approach was the catalyst for staff and providers to focus their attention on preventive measures and well visits.

Fast-forward to 2020 and six years of experience delivering value-based care, population health techniques have become an engrained component of the culture at McKenzie which has had a positive ripple effect on its rural community.

Recognized as a Top Performer – 76% of McKenzie’s traditional Medicare patients have had a wellness visit in the last 12 months. 

Early on, staff and providers recognized the value of the Annual Wellness Visit (AWV), and they worked with Caravan to create goals, implement workflows, and establish templates to ensure consistency. The AWV has become the key to seeing patients who aren’t sick or in need, to maintain their health, and to discuss preventive care. Patients have heard McKenzie’s, ‘one year and one day’ mantra enough to know that one year and one day following their AWV, they will be seeing their providers for another one. This type of communication and education has created opportunities for increased chronic care management and has improved overall outcomes for patients and providers.

Everyone plays an integral role including support staff, billing and coding experts, nursing staff, providers and the schedulers. McKenzie successfully uses centralized scheduling to the benefit of staff, providers, and patients. Schedulers block specific times for providers which helps the daily schedule run as smoothly as possible. Patients are scheduled according to category – sick visits, well visits, med reviews – and during the COVID-19 pandemic, these time blocks have worked well to keep high risk patients safer.

The results of six years of population health are undeniable:
•    Significant decreases in unnecessary ER visits
•    Improved patient outcomes
•    Patients are more engaged and take the initiative for their own health
•    There has been an increased in community health screenings
•    An increased number of patients enrolled in Chronic Care Management

“We have focused on population health for so long that we see it instilled in others. It’s become part of our culture and you see it in the hospital, in outpatient, in the clinics – we see it in our community.”
Debbie Ruggles
Director of Healthcare Practices
McKenzie Health System

Alcona Converts 100% of its Clinics to Virtual Care in Two Weeks

Based in Michigan, Alcona Citizens for Health, Inc. (Alcona) is a medical group with offices in nine locations. As one of the founding members of Caravan’s Collaborative ACO, Alcona has participated since 2014.

With population health practices well established among staff and providers, Alcona prepared to implement new methods of care in response to the COVID-19 pandemic. One priority was virtual care. Alcona’s specialty clinics had already opened their virtual care doors and had been successfully conducting BHI appointments from FQHCs. With one goal, to serve their patients to the best of their abilities, they expanded their virtual care services.

They began by looking at the providers who were already performing telehealth visits and one provider stepped forward to set the stage for the entire health system. Alcona ensured that providers, staff, and patients were equipped with the tools, resources, and information required to be successful by using well-engrained population health methodologies.

‘Drive-up Telehealth’

When challenges presented themselves, each time Alcona successfully course-corrected. When Skype wasn’t reliable in their area, they determined Zoom was. When patients didn’t have ready access to Wi-Fi, they created ‘Hot Spots’ in clinic parking lots – areas cordoned off specifically for telehealth appointments. For patients who didn’t own a smartphone or laptop, they provided tablets for them to use from the safety of their car – tablets donated by staff and employees, reformatted and prepared by IT teams to make them user-friendly. Every Alcona clinic had a ‘telehealth mini-launch’ that provided staff the resources and information they needed to develop workflows, use Zoom, ensure proper documentation and troubleshoot issues.

Within two weeks, Alcona had converted 100% of their sites to virtual care practices and were successfully seeing 35-40% of their patients virtually. The majority of patients were seen through telehealth from their homes and each day, between 35-50 patients had appointments from the ‘Hot Spot’ zone in the designated spaces in the parking lot. The ‘drive-up telehealth’ gave patients the ability to safely see and be seen despite having no access to smart devices or technology.

Today, Alcona has begun to see more patients in office settings, however they continue to see patients virtually from home and from the ‘drive-up telehealth’ parking spaces.
“Telehealth has worked out great, we’ve served so many patients we would not have been able to see if we hadn’t put this in place.”
Caitlin Schlappi, RN
EMR Coordinator
Alcona Citizens for Health, Inc.

Patient-Provider Relationships at the Heart of Ridgecrest Regional’s Chronic Care Management Success 

Ridgecrest Regional Hospital (RRH), is a full-service, acute care hospital located in Ridgecrest, CA. The hospital has been a member of Caravan’s Collaborative ACO since 2016 and is firmly established in delivering value-based care. Their Chronic Care Management (CCM) program includes 150 patients and between 40-60 patients are seen each month.

The program’s success is founded in the levels of trust that have been established between the patients and providers, including nurses who are highly skilled in population health. The nurses, who are enmeshed in the community, know their patients by name and have a well-developed camaraderie. The patients are receptive to the nurse’s suggestions and the patient-provider relationship has been the catalyst for the success of their CCM program.

‘Only a phone call or hallway away.’

When RRH providers are meeting with patients the CCM nurses are available whether it is a phone call during a virtual visit or on-call nearby for in-office visits. RRH’s nurse-led program includes successful steps such as:
•    Providing nurses with dedicated phone lines that allow patients the ability to contact them with immediate concerns or questions.
•    Giving the nurses the ability to refer patients to a health coach or Behavioral Health team when indicated.
•    Tracking all relevant information with a spreadsheet that displays the patient’s enrollment date, frequency of contact, most recent AWV, secondary payor source, etc.
•    Accessing a variety of customized reports created to help identify potential CCM patients.
•    Receiving alerts when their CCM patients are in the ER, Urgent Care, or are hospitalized.
CCM nurses work closely with community resources provided by RRH including senior services, support groups, and exercise programs that help patients with chronic conditions maintain their independence at the highest possible level of wellness.

Despite the challenges of the Public Health Emergency, RRH has maintained a continuity of care due to their successful CCM program and the well-established relationships with patients. Many of the community resources that were once offered in-person are now offered virtually. This virtual support has helped their CCM patients maintain their wellness during the pandemic.
“We have a well-established rapport with our patients and throughout the pandemic that foundation of trust has served everyone well. We’ve been able to maintain our communication and make sure our patients with chronic conditions are maintaining their health. This experience has proven to us how important these patient-provider relationships are.”
Celia Mills
Administrator of Care Coordination & Community Health
Ridgecrest Regional Hospital

Carle Foundation Hospital Initiated Chronic Care Management Outreach During COVID-19 Pandemic

The Carle Foundation Hospital (CFH) is a 433-bed Level I trauma center located in Urbana, Illinois. The hospital ranks as one of America’s 50 Best Hospitals and for more than ten years has held the Magnet® designation - the nation’s highest honor for nursing care. CFH includes more than 1,000 doctors and advanced practice providers - they joined the Stratum Med ACO in July 2019. 

During the public health emergency, CFH providers and thought leaders came together to determine a series of best practices to ensure the safety and promote health for their staff, patients, and community. One decision was to use an interdisciplinary team for Chronic Care Management (CCM), in order to make sure population health nurses had ample time to focus on high-risk patients.

In a successful collaboration, medical assistants initiated calls to patients, introduced the CCM program, and laid the foundation to begin patient care management. While a specific team consisting of a variety of physicians worked together on CCM, population health nurses worked closely with their high-risk patients. Well-versed in population health, screenings, and proactive questioning, the nurses were able to manage their higher-risk patients which prevented unnecessary hospital and emergency department visits. The nurses were able to convey essential messages on optimal health and safety measures and the CCM program began to grow. The increased communication has helped patients understand their changing environment and adapt to new dynamics which has helped to ease anxiety and stress levels. The CCM program is growing as providers have embraced population health.
“Our medical assistants started an outreach initiative to introduce our Chronic Care Management services. This led to gaining consent and now, we have an enhanced program and are effectively managing calls and coordinating our resources. Our patients have responded well. I believe what we’re seeing is the future of healthcare.”
Margie Zeglen, Vice President Population Health
Carle Foundation Hospital

Highlighting Best Practices During the COVID-19 Pandemic

Throughout the public health emergency much has been gained through the sharing of best practices and having opportunities for open dialogue. Early on, Caravan experts hosted COVID-19 educational webinars that quickly gained in interest and, the Q&A sessions at the end of each presentation grew longer. We saw that our ACO members were seeking more information and those with practices outside of ACOs were also interested in hearing what we had to say.

CMS has recently noted that ACO participants have managed pandemic conditions better than those who practice fee-for-service health care. Because the pandemic is far from over, it is critical to continue to stay updated on best practices. Increased outreach and virtual care are two best practices that have proven to maintain a continuity of quality care while generating revenue.

Increasing Outreach is an effective way to maintain communication with patients and encourage those with chronic conditions to enroll in a Chronic Care Management program. Outreach also enables patients who are fearful of leaving their homes during the pandemic a way to safely stay in touch with their care team and benefit from more information.

“We have enrolled more patients into our CCM program. I would like to continue this level of outreach after the public health emergency”, Shelle Berg, RN, First Care Health Center.

“Our weekly Town Hall forum on Facebook and YouTube has been a safe and easy way for us to communicate with our patients and provide them with resources and support”, Mindy McConnell, RN, Springhill Medical Services.
Implementing Virtual Care makes it possible to see patients in safe and healthy ways – especially those who are most vulnerable. Most patients have embraced telehealth and providers are successfully performing AWVs and other essential screenings using virtual care. An upcoming rule from CMS will include a proposal to permanently expand reimbursement for telehealth.

“We continue to offer our community and patients the care they deserve. We have been around for 75 years. Nothing is going to stop us now”, Kent Nicaud, President & CEO, Memorial Hospital of Gulfport.

“(We) worked creatively with Home Health Care, telemedicine, and other community resources to break the barriers to healthcare that many of our high-risk patients were experiencing”, Kathy Sawyer, RN, Witham Memorial Hospital.

First Care Health Center’s Outreach Included Mailing Masks to Patients

First Care Health Center (First Care) is a comprehensive medical center consisting of a critical access hospital and a rural health clinic serving the Park River community in North Dakota. First Care has participated in the Caravan Collaborative ACO since 2016.
Care Coordinator, Shelle Berg, recognized the need for community outreach as First Care began to implement preventive COVID-19 measures. She was concerned that their patients, particularly those who were Medicare-aged, would be hesitant to use telehealth and not want to ‘bother’ their providers during the public health emergency. The staff created a flyer describing the benefits of Chronic Care Management (CCM) and mailed the flyer, which included a mask, to patients identified as high risk, emotionally challenged, and high utilizers. They also sent the flyer and mask to caregivers of fragile patients. The overall goal for this outreach was to connect with their patients and let them know that they were still available to them during the public health emergency and that the patients could continue to receive care, safely from their homes. The flyer outlined their contact-free CCM program and also described additional available services including:
•    Personalized assistance developing a care plan
•    Nurse phone calls in-between and necessary clinic visits
•    Coordination of care, including referrals
•    Connecting with resources and other services
•    Medication and self-care support

“Our patients were extremely grateful to hear from us while they were staying at home, and we had patients calling in to express their thanks for the masks and interest in the program. They commented that they felt taken care of and in turn, we have enrolled more patients into our CCM program. I would like for us to be able to continue this level of outreach - after the public health emergency.”
Shelle Berg, RN
Care Coordinator
First Care Health Center

Nurses at Witham Memorial Hospital Have Made a Difference by Focusing on Virtual Care


Located in rural Indiana, Witham Memorial Hospital (WMH) is a member of the Suburban Health Network ACO. In their five years of active ACO participation, the staff have become experts in population health and adept at identifying at-risk patients and the social determinants that preclude them from accessing health care.

As the COVID-19 pandemic enveloped the nation, WMH providers implemented preventive measures to minimize risk and spread of the coronavirus. The staff collaborated with home health partners who assisted patients with technology and virtual visits which opened the virtual doors of communication for a continuation of CCM visits. The partnership with the home health professionals helped staff identify patients who were likely in need of therapy and services such as injections or other procedures.

Many patients were afraid to leave their homes to seek care and were feeling isolated and alone. Some patients had become weak from sitting too long which could lead to falls. The public health emergency resulted in lowered patient volumes which afforded staff opportunities to call recently discharged patients with a specific focus on patients who had refused post-acute care. Nurses coordinated with their telemedicine team to have labs drawn and EKGs done in patient’s homes.

By focusing on virtual care and patient safety, nurses placed nearly 100 more proactive outreach calls in April than in months prior. During one call to an elderly man, it became apparent that he was struggling. His wife was diagnosed with COVID-19 and in a rehab facility. A PHQ-9 indicated that he was experiencing depression and at risk. Acting quickly, a virtual visit with his physician was scheduled, medication was prescribed, and care was coordinated with the home health partners who arranged their schedules to optimize the cadence of visits. In addition, the rehab facility was contacted, and visits were arranged so he and his wife could connect virtually. Today, both have recovered, are at home, and coping well.

The unexpected isolation and fear produced by the COVID-19 virus restrictions, put an already vulnerable population at risk for collateral problems. The Witham team worked creatively with Home Health Care, telemedicine, and other community resources to break the barriers to healthcare that many of our high-risk patients were experiencing during this time.”
Kathy Sawyer, RN
Care Coordinator  
Witham Memorial Hospital   

Springhill Medical Services Host Weekly Town Hall Forums to Improve Care 

Springhill Medical Services (SMS) is a rural health system located in Springhill, LA. Consisting of a 58-bed community hospital, five rural health clinics, and outpatient physical therapy. They have participated in a Caravan ACO for two years and serve a community of limited resources. 

At the onset of the public health emergency, Michael Patronis, CEO, recognized the key to limiting the spread of the coronavirus in their community was communication. SMS providers felt a great responsibility to provide as much insight and education as possible to help educate and safeguard their community. Together, the SMS staff developed a weekly Town Hall forum in order to maintain a pathway for communication and care.  

The Town Hall forums are broadcast via Facebook Live, YouTube, and can also be accessed via telephone dial-in capability. Each week, the CEO and providers share new information and connect residents to resources and available services such as telemedicine, COVID-19 testing and diagnostics, and access to health care during the pandemic. The sessions are interactive and community members have the opportunity to ask questions.  

The forums have been a great success and staff and providers have commented that it has brought them closer to their patients and community.  

“The COVID-19 pandemic was a game-changer for us. We knew we needed to rise to the occasion to not only be prepared to treat and care for our patients, but we also needed to be proactive in accurately informing and helping to educate our community. Our weekly Town Hall forum on Facebook and YouTube has been a safe and easy way for us to communicate with our patients and provide them with resources and support. Their questions have helped us understand and meet their needs.” 
Mindy McConnell, RN  
Population Health Nurse 
Springhill Medical Services 

Nurse-led Outreach at Lane Regional Medical Center Prevented ED Visits

Lane Regional Medical Center (LRMC) is a 139-bed hospital located in Zachary, LA. As members of a Caravan ACO since 2018, the hospital staff were highly skilled in population health and routinely screened patients for chronic conditions - including behavioral health concerns. When the risk of COVID-19 began to impact the nation, the hospital proactively contacted their CCM patients who were already identified as high-risk and/or struggled with depression. As the hospital implemented best practices to minimize the spread of the coronavirus, their patients were kept up to date with changes and new information. The staff also took steps to identify available community resources and shared the information with physicians and patients.

The increased communication and outreach from nurses and staff during the pandemic resulted in zero ED visits or admissions from patients enrolled in CCM! The outreach effectively prevented all CCM patients and their families from unnecessary visits to the ED which would have increased the risk of infection and spread.
The outreach has been so successful that LRMC and Lane Family Practice are in the process of developing plans for a strategic re-opening. The nurses and staff continue to reach out to patients to ensure they are informed and educated on precautions and safety policies.
“Our approach has been to increase our outreach to our patients and make sure they understood our new protocols and why we were implementing them. This experience has demonstrated just how effective we can be with outreach. As we move toward a phased re-opening, we will continue to keep our patients informed and they’ve learned that they can call us any time they have a question or concern. We’ve made sure they understand the phone works both ways – we are encouraging them to call us as well.”
Amy Rome, RN
Population Health Nurse
Lane Regional Medical Center

Memorial Hospital at Gulfport Overcame Obstacles & Transitioned to Telehealth

Memorial Hospital at Gulfport (MHG), part of the Myriad ACO, is one of the most comprehensive healthcare systems in Mississippi. They are licensed for 328 beds, including a state-designated Level II Trauma Center, three nursing centers, three outpatient surgery centers, satellite diagnostic and rehabilitation centers and more than 100 Memorial Physician Clinics.   
Prior to the COVID-19 pandemic, MHG had minimal telehealth usage in the ambulatory setting. However, after watching the Caravan COVID-19 webinar, ‘Reengineering Primary Care’, Dr. Sean Kerby contacted Dr. John Findley for guidance. Equipped with new information, Dr. Kerby worked with Matthew Walker, ACO Champion, to develop and implement a workflow that ensured all CMS guidelines were followed.
Five Population Health Nurses (PHNs) attended a one-day, hands-on training session and identified obstacles that needed to be addressed. The PHNs worked with each provider to customize workflows to accommodate the needs of each clinic. The nurses have helped patients overcome barriers including limited access to internet or experience with smartphone technology and how to navigate the telehealth platforms. They have been successful. Patients report to being more comfortable in their home environment and the nurses have noted that their patients seem relaxed and are sharing more information. By May 12, the PHNs had completed 107 AWVs as telehealth dual visits!
Due to their telehealth success, MHG plans to continue utilizing telehealth for AWVs in whatever capacity CMS allows.  Telehealth has proven to be a positive encounter for the patients and the PHNs. By mid-May, all PHNs had attended training and education for all providers was taking place.
“As we continue to take one day at a time and to continue to offer our community and our patients the care they deserve, we know that a new day is coming, and with it, we will draw strength, new ideas and experiences. After all, we have been around for 75 years. Nothing is going to stop us now!” 
Kent Nicaud, President & CEO
Memorial Hospital at Gulfport

Sullivan County Community Hospital

The rural-based hospital served a widespread community that lacked resources. To improve care and generate sustainable revenue, the hospital joined a Caravan ACO. Using data provided by Caravan, hospital staff could better identify the needs of their patients and connect them to available support and resources. Benchmarks were set and staff had a foundation for Quality Measures. The results speak for themselves.
2017 to 2018 Year-to-Year Comparisons Demonstrate Significant Improvements
•    33% increase in Diabetes Eye Exams
•    32.8% increase in Preventive Care & Screening for Influenza Immunizations
•    28% increase in Pneumonia Vaccination Status for Older Adults
•    20% increase in Preventive Care & Screening for Screening for Clinical
•    13% increase in Controlling High Blood Pressure

Tampa General Hospital Increases Population Health Revenue by $1 Million

Serving four million residents in West Central Florida with a wide range of specialists and clinicians, Tampa General turned to Caravan Health to implement and sustain a new population health infrastructure. The results? Six months after joining the collaborative ACO, Tampa General increased its population health revenue by $350,000. Within one year, the hospital realized $1 million in newly generated revenue. Here’s how they did it:
  • Tampa General hired three population health nurses and one medical assistant to support the new services.
  • The hospital relied on Caravan’s nurse-led model to gain physician acceptance.
  • Caravan data highlighted gaps in care and opportunities for growth.

Huntsville Hospital Identifies Gaps in Care through Enhanced Data Analytics

Value-based care was a new concept to staff at rural Huntsville Hospital in northern Alabama. But with the help of Caravan, they soon learned that they didn’t have to reinvent the wheel.
Hiring population health nurses for the first time opened new opportunities and they quickly increased their AWVs. The hospital relied on Caravan Health’s training resources and workshops to ensure their operational systems were optimized. The staff learned the value of data analytics to identify patients who were missing appointments and not following through with acute care instructions. The hospital generated population health revenue and shared savings within their first year of joining the ACO. Next, the hospital plans to enhance its focus on chronic care management to ensure their community receives the best care while lowering costs.
“ACOs are our first delve into population health and risk-based contracts and payments. You’ve got to have data to drive you forward and identify gaps in care and turn that into results. In my opinion, population health is the future of medicine.”
 Jay Morrison, M.D.
 Medical Director, Huntsville Hospital Health System, Huntsville, AL


Winston County Medical Center Shares Mississippi ACO Patient Success Stories 

As part of the Myriad Health Alliance ACO, Winston County Medical Center in Louisville, MS, is a full-service facility that serves as the county’s only hospital. Population health encourages staff to consider the social determinants of health as part of the holistic approach. Winston County Medical’s demographic is typical of rural communities that struggle with access to health and increasing AWVs is one way to improve patient outcomes.
 In one example, a nurse noticed that an indigent patient they had treated for three years was not showing improved blood sugar levels or decreased blood pressure, despite medication. After reviewing results of the AWV, the nurse deduced that the patient was unable to read and did not understand the prescription instructions. The instructions were delivered differently, patient understanding was verified, and the test results improved.
“If you just have one success story like that a year, I think we’ve accomplished something. That’s probably been our biggest thing – whenever our patients come in for annual wellness visits, the nurse that performs the (exam), she covers every screening that they should have.”
 Debbie Fryeri, Director of Clinical Operations 
 Winston County Medical Foundation


Population Health Practices at Magnolia Regional Health Center Lead to Early Diagnosis   

Recently, Jessica Tyler a Clinic Nursing Services Manager at Magnolia Regional Health Center in Corinth, Mississippi, shared an example of how population health techniques led to early diagnosis and treatment of one of their patients.  
During an annual wellness visit, a population health nurse engaged the patient in conversation as she conducted screenings. In response to a question posed by the nurse, the patient commented that she sometimes experiences stomach pain but hadn’t given it much thought. As the nurse continued to talk with the patient, she noted the intermittent pain and accompanying symptoms and concluded that there could be more going on. She referred the patient to a specialist who diagnosed a kidney tumor. Due to the early diagnosis, treatment began immediately and prevented what would have likely resulted in an early death for the patient. 
This is one of many patient and provider success stories that routinely happen when practicing population health care. Thank you, Magnolia for your commitment to your patients and this work! 

Margaret Mary Health Prepares its Rural Community for COVID-19 

Located in rural Batesville, Indiana, Margaret Mary Health serves a rural community with its critical access hospital that provides inpatient and outpatient services. Tim Putnam, CEO, participated in the first of Caravan Health’s ongoing educational COVID-19 webinar series and shared his hospital’s experience with a patient who tested positive for the novel coronavirus, having staff under quarantine, and planning for worse-case scenarios.

Staff quarantines are a concerning situation for every health system and particularly so for smaller rural-based hospitals with fewer staff. At Margaret Mary, one patient with shortness of breath who came in for a chest x-ray, tested positive which resulted in three staff members being placed in quarantine.

Regarding the quarantine concern he stated, “If I lose a surgeon or a couple of anesthesiologists…an ER physician…we lose the ability to provide care to our cardiac patients and the patients who were in accidents.”

Tim described the measures he has taken including recording a daily video message for staff and releasing video messages with the Mayor which has helped to inform their community. He has set up a COVID-19 24-hour Hotline for concerned citizens to call with questions and receive information.
His preparation also includes:
•    Re-directing & cross-training staff
•    Staging for different levels of triage & care
•    Segregating the organization to a clinical and non-clinical side.

He added, “We are taking a lot of extra precautions which is putting a lot of pressure on our supplies – we’re beginning to ask staff to store their used masks with a silicone gel in case we have to reuse them. We’ve implemented visitor limitations.”

To hear more from Tim Putnam and how his hospital is preparing, along with a Q&A, you can watch the webinar here.

Year of the Nurse

The World Health Organization (WHO), has designated 2020, the ‘Year of the Nurse’. In honor of this, each quarter we will highlight a nurse in one of Caravan’s collaborative ACOs. This week’s Spotlight shines on Nicole Tabert, RN and Clinical Coordinator for Samaritan Healthcare in Moses Lake, Washington.  

In 2019, Samaritan joined the Caravan ACO, and assembled their first population health team. Together, they attended trainings, learned best practices, and transitioned to value-based care. Prior to joining the ACO, the staff nurses were not working at the top of their licenses, there was no chronic care management (CCM) program in place, and they had completed a total of 18 annual wellness visits (AWVs). 

With benchmarks in place, Nicole worked with her team to increase the numbers of AWVs. She routinely scheduled 2 FTE RNs to perform AWVs and she didn’t stop there. Nurses used the AWV to identify patient need for CCM and, the clinical staff worked to engage community health workers. 

Nicole’s efforts have paid off. They have multiple patient success stories, including one patient who was identified early with congestive heart failure which resulted in intervention that has prolonged his life. 

In year one, Samaritan increased their AWV rate by 18%, and went from no CCM program to one that receives daily referrals. Increasing their HCC coding recapture rates by 65% resulted in more than $600,000 in new revenue. Inpatient admissions and emergency department utilization rates have decreased. 

Congratulations, Nicole for a job well done – you are an inspiration for nurses everywhere. 

Greer Duran, Cassandra McCoy & Casey Rankin: Three Nurses Putting Their Community First

In Jackson, Mississippi, the MEA Medical Clinics are comprised of health care professionals who have been an inspiration to Caravan Health employees since they joined the Myriad Health Alliance ACO. The clinics serve a vast community and in response to the COVID-19 pandemic, a triad of dedicated nurses are making sacrifices on behalf of the communities they serve.
All three nurses have committed to being on site to screen each employee and take their temperature as they arrive for their shift at the local factories. The factories run 24/7 operations which require the nurses to be on site every eight hours – around the clock. And, they are continuing to proactively call their chronic care management patients, add new patients to their caseloads, and schedule telehealth Annual Wellness Visits while they work remotely.
During the public health emergency, these three nurses are away from home, staying at hotels, and seeing families on the weekends in order to ensure that hundreds of employees are screened each day to prevent a COVID-19 outbreak within the factories.
This week is National Nurses Week. We are honored to acknowledge Greer, Cassandra, Casey, and every nurse whose dedication to their patients and communities are helping to make our world a safer, healthier place.

McKenzie Health System Receives PPE Made by Students Using 3D Printers

McKenzie Health System is a Critical Access Hospital located in Sandusky, Michigan. The rural hospital system has been a member of a Caravan ACO since 2014. At the beginning of the COVID-19 pandemic and Public Health Emergency, PPE was not readily available or easily accessible for rural Michigan hospitals. Statewide news coverage reported on the lack of supplies and concern that some of the hospitals may not have access to the protective gear they would likely need.

In Sandusky, a group of high school students who are members of the Enigma Robotics 2075 team, learned about the concern their community could be facing and decided to do something about it. They used their 3D printing skills to develop a method to make face shields and ear savers.

One of the advantages of 3D printing is the ability to produce complex shapes that are accepted as viable forms of industrial-production technology. The students developed their models using CAD files and made 100 face shields and 200 ear savers for their local hospital. Clinicians are wearing the face shields and the ear savers daily – an example of community support in action.
“We appreciate the energy and time the robotics team put in to supplying us with personal protective equipment as it is incredibly important to the nurses and physicians who are treating patients.”
Steve Barnett, DHA, CRNA, FACHE
Chief Executive Officer
McKenzie Health System

 Confluence Health Emphasizes Proactive Outreach During COVID-19 Pandemic
Confluence Health serves 12 rural communities throughout North Central Washington. Located in Wenatchee Valley, the health system joined the Stratum Med ACO in July 2019 and began implementing value-based care and holistic practices.

The first confirmed case of the coronavirus in the United States was in the state of Washington, and providers at Confluence Health were quick to respond. As COVID-19 became a national reality, clinicians at Confluence took a wide-angled approach to preparing for the virus and preparing for its anticipated ripple effect.

Social distancing and quarantine measures disrupt lives and carry the potential to trigger mental illness or behavioral health vulnerabilities. Given their rural population and older demographic, the Confluence team was concerned about surges in the rates of depression and anxiety in their patients. They began making proactive outreach calls to patients who had depression and/or anxiety prior to the public health emergency. Nurses spoke with patients to uncover potential concerns and needs that may had otherwise gone unnoticed. Leaders communicated the heightened importance of population health practices with all clinical teams.

During an ED visit regarding a possible positive COVID-19 patient, the physician was concerned about the patient’s severe dementia and requested a CCM consult. The population health nurse made a house-call to assess the patient and her circumstances. The nurse discovered that the discharge medications had been sent to the wrong pharmacy – located in another city – and the patient was still waiting for them to be delivered. If not for the nurse’s intervention, the patient would likely have returned to the ED possibly increasing her exposure as well as others to the coronavirus.

By communicating their proactive and preventive practices, Confluence clinicians are effectively treating their patients while protecting them and their colleagues from unnecessary risk.
“Social distancing and extreme changes in daily life all have the potential to lead to a surge in clinical depression or anxiety in our rural community. We recognized this as we began preparing our staff for the pandemic and put proactive plans in place to make sure we’re monitoring all aspects of our patient’s health. This is what value-based care is all about.”
Edwin Carmack, M.D.
Medical Director of Value Based Care
Confluence Health

Madison Memorial Hospital Expanded Telehealth Services to Offer Consistent Care Delivery

Prior to the COVID-19 pandemic, Madison Memorial Hospital (MMH) had not deployed any telehealth or virtual care to their patients. The rural facility, based in Rexburg, Idaho, had recently joined the Eastern Idaho Care Partners ACO, and had begun the transition to value-based care.

The hospital administrators and staff responded quickly when CMS began to promote telehealth services with fewer restrictions. By recognizing the potential implications of the coronavirus on their community, they designated a core team to understand the components required and set about to launch their first telehealth services.

Working at a fast pace, they researched the availability of reliable internet connections across their community and software that would effectively streamline appointments in a virtual environment. They proceeded to put systems in place for their essential employees including the front office staff, providers, and clinicians to access their new telehealth software.

The team looked at each part of the telehealth visit and analyzed the processes needed to make sure their patients received quality care, despite not being in the office. They understood their community had no experience with telehealth and made efforts to ensure the process would be smooth for patients. The reassurance they provided to their community was particularly important during this pandemic.

As our nation grapples with the coronavirus, MMH has a well-received telehealth care plan in place. In their first month patients, who had begun to acclimate to value-based care, have responded positively with little-to-no resistance. The team invested many hours developing their workplans and today, patients and providers have embraced the technology with the understanding that it is the best way to keep their community safe while ensuring their patients have access to their providers.

“We recognized quickly that telehealth and virtual visits would be the key to keeping our patients and staff protected. Now that CMS has expanded telehealth services, we’ve embraced this new option and for a small, rural community, our patients have supported our efforts. It’s a collective effort that protects everyone.”
Heidi Riphenburg
Quality Projects Coordinator
Madison Memorial Hospital

Barrett Hospital & Healthcare Quickly Implemented Proactive Protocols during COVID-19 Pandemic

Barrett Hospital & Healthcare (BHH), is a critical access hospital located in rural Dillon, Montana and has participated in a Caravan ACO since 2016. The hospital serves an area greater than Rhode Island and Connecticut combined. When notified of the first COVID-19 case in their county, they responded quickly. 
The hospital took a strategic approach to prepare for a potential outbreak in their expansive rural area and implemented steps to protect their clinicians, hospital staff, and community. Whenever possible, all staff meetings were immediately transitioned to Zoom calls to protect employees. The hospital immediately set incident command in place with their county which, coupled with the Zoom calls, resulted in successful actions that have helped keep the community, and those caring for them, safe. Today the staff is implementing new virtual care workflows. Below are some of the key steps BHH took: 
  • Each provider highlighted their at-risk patients and chronic care managers provided scripts for all available staff to place calls to every person to make sure needs were met. 
  • Designated a ‘COVID-area’ to the hospital including triage, hot & cold areas. 
  • Developed a plan with surgeons & OB-GYN providers for COVID-positive patients. 
  • Established morning check-ins for all staff prior to beginning their shifts. 
  • ‘No Visitor’ policies extended to the assisted living & nursing facilities where all staff are screened twice a day for symptoms & temperature. 
  • Initiated virtual care & telehealth visits. 
  • Engaged community resources including a resident with Ebola experience to assist in PPE equipment, set up volunteers to deliver groceries & developed a payment process. Community outreach resulted in local grocers designating specific shopping hours for high-risk individuals & pharmacy delivery. 
  • They are implementing plans for a secondary impact on the mental health of staff & community while the BHI team contacts at-risk patients using virtual care. 
“This was a community effort that relied on all the members of our community to actively participate in the recommendations for isolation.  From those in business, those in the church communities, volunteers in the community; to those in the medical arena everyone stepped forward to keep our community safe.” 

Anna Loge, M.D. 
Barrett Hospital & Healthcare  

Tallahatchie General Hospital Nearly Doubled the Number of CCM Patients in Six Months

Tallahatchie General Hospital (TGH), is a critical access hospital with a nursing facility and RHC in Charleston, Mississippi. TGH is part of Myriad – a statewide collaborative ACO. After joining in 2019, the staff were trained on population health and nurse-led models.

Caravan helped them recognize the potential to improve patient care and increase revenue by enhancing their CCM program. By developing a role for a Population Health Director and utilizing their current staff, they openly communicated with the providers and explained the opportunities. The providers gained consent from patients to use telehealth services which signaled the CCM team to contact the patient – which they accomplished within two days.

The program has been successful. Despite the COVID-19 pandemic, TGH increased their numbers of CCM patients from 400 at the end of 2019, to nearly 800 today. Plans are in place to complete a PHQ-9 on each patient during the month of June to screen for potential mental health concerns.
“There are so many ways for a CCM program to go wrong and ours was stuck for some time. What changed our program was hiring Mike Chandler in his role as the Population Health Director. It is not only important to have the right person in the role but also to have a good process in place to get the providers onboard.” 
Buddy McRae, COO
Tallahatchie General Hospital
Charleston, MS


Recent Resources

CMS Actions in Response to the COVID-19 Public Health Emergency

The Centers for Medicare and Medicaid Services just issued a lengthy set of policy changes to address the growing COVID-19 public health emergency (PHE). These changes will help hospitals and health providers to respond to the crisis more quickly and safely, including many more options for telehealth in Medicare.

ACO, Policy, Webinars & Events, Quality, Value-Based Care, COVID-19

Stop Standing Still: How to Get Started in a High-Performing Caravan Health ACO

Tuesday, September 24 at 9:00am PT / 12:00pm ET

ACO, Webinars & Events

10 Reasons ACOs Can Fail

Just published in Becker’s Hospital Review – Caravan Health Senior Vice President Tim Gronniger discusses ten reasons Accountable Care Organizations can fail.

ACO, Blogs & News, Value-Based Care


Learn the latest in value-based care - check out our resources page

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