Rather than providing care in a reactive way, by addressing the issue that comes up when a patient comes into a practice or visits an emergency room, Caravan Health is pushing for a more proactive model. We understand that this requires a continuous and coordinated conversation among various providers on the care team, not just a short visit with a PCP.
To help ACOs understand what this paradigm shift requires, we spoke to John Findley, MD, Caravan Health’s Medical Director of ACO Programs. In this role, he supports physician leaders at the ACO and community level in their practice redesign efforts. This work builds on Dr. Findley’s 15 years of experience practicing family medicine in western Colorado. His practice was an early participant in the Comprehensive Primary Care Initiative, which was the precursor to the Comprehensive Primary Care Plus program that aims to improve access, quality, and efficiency of primary care practices.

How do you pull together numerous, diverse roles – care coordinators, nurses, population health nurses, physicians, and so on – to collectively improve the patient experience?

The team can work together to use the claims data that they have at their fingertips from CMS to come up with actionable lists of specific cohorts of patients and conduct active outreach. The data enables us to do that – and we could never do that before. Ten years ago, family medicine doctors could not tell how many diabetics they had in their population. Now we are giving them an actual picture of the population they serve, and what is the greatest need.
It enables various people on the care team to have more face time with the patient, to help patients get a better understanding of their disease condition, of the importance of a treatment plan.
By building a stronger relationship, we will continue to see improved outcomes. We've already seen early evidence that making a concerted effort to do more annual wellness visits and complex care visits can lead to improvements in diabetes care – more people get an eye exam to make sure they're not at risk for blindness. Those little things really can make a big difference, and it’s because patients get extra time with various members of that care team.
Health care is facing what I call the “triple tsunami” of increasing chronic disease (such as obesity, hypertension, and hyperlipidemia), an aging population, and an estimated provider shortage. Team-based care is the only way we will address all these needs – and that will demand a much broader team, with much broader capabilities. Physicians need this now more than ever.
"By building a stronger relationship, we will continue to see improved outcomes – and it’s because patients get extra time with various members of that care team."

What do you see as the biggest needs for the physician leaders that Caravan Health is supporting?

The Triple Aim drives a lot of this conversation for the cost of care for a population as well as the patient experience, but there's been more acknowledgement of the importance of that Quadruple Aim that addresses physician well-being as well. It’s been estimated that, in order to meet standard clinical care guidelines for chronic disease management, acute care, and preventive services, family medicine doctors would have to spend near 22 hours per day caring for their patient panels.
Primary care is no longer a task of one. Part of what drove me to Caravan Health is our support for practices in the trenches – helping them implement new workflows, both from a technical standpoint and in terms of clinical capabilities and competencies, to build that top-of-license capability. I absolutely believe that team-based care gets to the core of what top-of-license means. My primary focus going forward is helping our ACO directors work with their physician leaders to carry the message of why this is such important work.

Your background is helping rural health systems. How do their needs differ from a large health system or even a mid-tier health system?

The needs in rural America are vast, and they've been massively underacknowledged. A lot of people live in isolation. They don't have access to the resources that you might have in a larger organization. Plus, there are significant health literacy issues, vocational rehab issues, and substance abuse issues that need to be addressed.
Caravan Health is a leader in helping rural ACOs reduce costs while achieving quality. Read more about the first CMS report on the ACO Investment Model.
It will take a bigger team of social workers and behavioral health providers to really dig into that – and it's not realistic for health care systems to provide these services on their own. A lot of the community hospitals that cover the majority of care in this country don't have deep pockets. They have declining margins and an inability to hire the staff necessary to do this. They rely on the sustainability of programs such as the CMS Quality Payment Program.

How can Caravan Health’s Collaborative ACOs help these types of health systems?

One criticism from my physician peer group is that they don’t trust data – the variation that comes in those smaller populations really exacerbates that problem. I'm excited about the Collaborative ACO model being the catalyst to push us to a whole other level of data analytics capabilities. A lot of organizations know they've got to jump into the ring and figure out how to build new competencies for value-based care, but I do think there's a cautionary tale about going at-risk with data that's not big enough to be statistically significant.

Caravan Health helps physicians and hospitals work together to create, operate and manage successful population health programs that improve patient care, clinician satisfaction and financial performance.

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ACO, Policy, CMS