Many population health strategies focus solely on treating high-cost patients with most of the responsibility left on physicians. While this is an intrinsic element to population health management, Caravan Health’s model thinks globally. We’ve found that by implementing a team-based approach to the health and wellness of an entire population, hospitals can sustainably improve patient care, increase revenue, and alleviate physician workloads.

What’s our secret?

Nurses. The Caravan approach maximizes the role of nurses to drive population health initiatives while taking advantage of reimbursements through incident-to billing. In our webinar “Ace Quality and Population Health by Doing Less Work, Smarter,” Caravan’s CMO Dr. Anna Loengard outlines the key components to leveraging nurse-led care that will achieve value-based success.


Our ACO partner results show the true value in utilizing nurses for wellness and prevention services. With appropriate training, nurses are better equipped to spend more time on patients, allowing them to treat and diagnose patient barriers physicians would otherwise not have the time to delve into. These services also quality outcomes and close care gaps for patients, which in return, ensures patients get the care they need and the burden of quality reporting goes down.

Additionally, the Centers for Medicare & Medicaid Services’ (CMS) Incident-to Billing codes have widened the opportunity for nurses to conduct elements of the annual wellness visit under the supervision of a physician while getting paid for it. Services such as wellness visits, transitional care management, chronic care management, advanced care planning, behavioral health integration, and cognitive assessment and planning are all ample opportunities to increase revenue streams without increasing physician burdens.

By engaging and empowering nurses, health systems can support primary care and make practice transformation sustainable. To dive deeper into Caravan’s results and model for success, read our interactive ACO guide.


Recent Articles and News

September 20, 2019

Year Two Results for ACO Investment Model Show Rural Value-Based Payment is Stronger Than Ever

Last week, CMS published the second year evaluation of the ACO Investment Model (AIM). AIM provided two years of upfront funds to smaller rural accountable care organizations venturing into value-based payment.

ACO, News, Policy

May 07, 2019

CMS Unveils New Primary Care Value-Based Payment Models to Start in 2020

In late April, CMS introduced five new value-based payment model options that aim to transform primary care and shift providers to take risk on the cost of care for their patients.

ACO, News, Policy, CMS

March 28, 2019

Firsthand Experience with Accountable Care in Oregon - Interview with Dr. Divya Sharma

An accountable care organization can transform how care is delivered and prioritize new approaches to population health and primary care. We recently had a conversation with one of our ACO physician leaders, Dr. Divya Sharma, Chief Medical Officer for the Central Oregon Independent Practice Association in Bend, Oregon, about the most important lessons learned from joining an accountable care organization.