Caravan Health’s ACO model is driven by data. Gathering and studying clinical and claims data helps our clients determine where to focus their efforts to provide high-value care at a lower cost. This actionable analysis is valuable to the entire organization – from executive leadership setting strategy to frontline clinical staff.

 Min Tao, PhD, is Caravan Health’s Vice President of  
 Clinical Analytics. We asked her to discuss the role of  
 analytics in driving decision-making around
 population health management strategy, and to
 provide some examples. She also talked about future
 initiatives to help health systems gain even more
 insight from the data they already have. 


How can and should health care organizations embrace analytics as part of their population health management initiatives?
Analytics plays an important part in population health management. Better understanding your population is all about using analytics to assess their risks, and the needs of individual patients, and then being able to deliver the appropriate care for patients’ needs. For the healthy patients, it’s strategies to help them stay healthy. For the patients with chronic conditions, it’s helping them manage those conditions so they don’t – or are less likely to – develop long-term complications.
Some health systems have been on the journey longer, so they have a lot of experience working with analysts to use the data to guide their strategy development. Others are just getting started on this journey. This can be a challenge, so we try to work with health systems at different levels and then meet their needs accordingly.

We work with health systems to see the value of data and analytics and to form the habit of using them as part of their daily operations.

How do you help health systems better understand how to use data to drive strategic decisions?
Right now, my team and I are focused on using analytics to help health systems identify opportunities for performance improvement. This is always tailored to them, specific to their needs and business goals, but also applicable to the broader goals of value-based care. We provide data for their quarterly board meetings and for committee meetings, which cover both care quality for their ACO populations and care cost and utilization trends. We monitor their performance over time to help them understand where they are now and how they have been trending to get there. 
We also work closely with the Clinical Practice Improvement Managers to help them understand how the data that we provide to them can drive a local strategy. During those quarterly meetings, for example, they can use our data to set priorities for improvement in the next quarter and identify what information they will need to collect to measure their progress.
We try not to be a team that just puts numbers out there. Health care tends to think in terms of descriptive statistics – inpatient utilization rate, ED rate, etc. Digesting and synchronizing that data, and then coming up with strategies for acting on what the data is telling you, can be overwhelming. A lot of our recent development work has focused on turning data into actionable reports to help clients make better decisions. That way we can work with health systems – including those that are at the beginning of their journey – to see the value of data and analytics and to form the habit of using those tools as part of their daily operations. 
In looking at the clinical and claims data that you have access to, have you seen any trends related to utilization among the communities where clients are based?
Our goal, in having access to this data, is to help health systems optimize their outcomes given their local context and their local economy. One ACO identified post-acute care as a key initiative to reducing its care costs. For such an initiative to work, though, providers have to refer patients to facilities that provide high-quality, low-cost care. We looked into the ACO’s data and created several metrics to help compare the skilled nursing facilities within the referral network, giving providers the information they need to refer patients to the high-performing SNFs.
On a broader level, we have also seen some success with preventive services. One good example us the pneumococcal vaccine – as a local community’s vaccination rate improves, hospital admissions due to community-acquired pneumonia decrease. 
Another example is the annual wellness visit. We see in our data that using these visits to build a relationship with a patient and conduct an overall needs assessment helps to close care gaps such as vaccines and A1c readings. Plus, as we collect more data over time, and as our client base increases, this gives us more statistical power to examine the relationship between preventive services and financial outcomes for our ACO clients.

Learn how Mammoth Health is using analytics to identify high-cost patients and make appropriate changes to their care.

What are some of your future plans for using analytics expertise to help health systems?
We use advanced data mining techniques that will proactively identify outliers in data sets or changes in data trends. We work closely with Caravan Health regional teams to make sense of the analytic outputs within a local context, and with clients to sit around the table and design and develop programs with clinicians.
I see our role as helping health systems generate a spark – they take the information we give them, interpret it in their local context, and find ways to design some kind of intervention or process change. This will result in downstream outcomes improvements that we will be able to measure and observe.

Caravan Health helps physicians and hospitals create, operate, and manage successful population health programs. Our programs improve patient care, client satisfaction, and financial performance. 

Contact us to learn more about how the role of analytics in helping our clients make the right decisions to improve patient care and control care costs.

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