July 08, 2020


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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


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