September 09, 2020


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Doing so strategically can ensure a successful segue to value-based care.  Adapting to population health-centered care requires a commitment to best practices, including putting nurses at the forefront of preventive care delivery to gain new revenue streams, an essential part of the preparation for risk. For some, making the commitment to change is met with resistance. Some ACOs have failed by trying to go it alone. Without enough attributed lives, no ACO can be truly prepared for ACO success.  

However, with the right preparation and infrastructure in place, those willing to make the commitment to population health and transition to value-based practices success can make it work. In 2019, administrators at Tampa General Hospital (TGH) joined an ACO in order to reach their goals of improving the quality of deliverable care while sustaining Medicare cost savings. 

One year after joining the ACO, the expansive tertiary and quaternary care facility with more than 1,000 beds serving residents of West Central Florida had quickly found their recipe for ACO success.  

The successful recipe, it turns out, was provided by Caravan Health - after its ACO experts had assessed TGH’s needs and weighed the hospital’s strengths, weaknesses, and identified potential areas for improvement. Under the guidance of Caravan, TGH hired three population health nurses and one medical assistant to support the new services. The staff was trained in population health methodologies, learned to use claims data analytics to uncover gaps in care, and make strategic care decisions to benefit the patient and ultimately improve outcomes. 

As TGH staff worked with Caravan, they focused on improving the effectiveness and efficiency of four essential components: 

  • Annual Wellness Visits 

  • Chronic Care Management 

  • Advanced Care Planning 

  • HCC Coding 

According to Dale Aggen, Director of Managed Care, concentrating on the four components helped them to form a discipline and strategic mindset, “This type of work and disciplined approach will only help our bottom line.” Indeed, by the six-month point, TGH had increased its population health revenue by $350,000 and was demonstrating steady progress each month. As success begets success, physician buy-in continued to increase as they began to realize more capacity to spend time with high-risk patients while population health nurses worked at the top of their licenses performing more screenings, chronic care management, and advanced care planning. 


Improving Patient Outcomes with Population Health 

In a short amount of time, the enhanced focus on patient care using population health methodologies has made a significant difference in overall outcomes. One recent example highlights the benefit of the improved patient-provider relationship. Adrienne Holmes, 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 population health screening, the patient 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. Today, the numbers speak for themselves: the patient’s cholesterol numbers dropped from 144 to 127, triglycerides dropped from 148 to 116 and today, and 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.”, commented population health nurse Adrienne Holmes. 

Recognized as the nation’s leader in accountable care, Caravan Health not only offers urban and rural health systems a customized recipe for success, they also manage the largest-ever collaborative ACO serving close to 600,000 attributed lives. Caravan Health ACOs have returned more than $108 million in total shared savings to providers nationwide. By using the model provided by Caravan, TGH codes and bills for nurse-led population health care, has identified gaps in care, enhanced their Annual Wellness Visits with more screenings which has led to increases in the numbers of patients enrolled in Chronic Care Management.  

One year, one million in new revenue. 

Within one year of ACO participation, TGH has generated $1 million in population health revenue and helped the expansive system attain their goals of improving the quality of care while sustaining Medicare savings.  

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