Rural Providers Narrow Population Health Disparities Through ACO Participation

Kansas City, MO, July 18, 2017 (GLOBE NEWSWIRE) -- Caravan Health has released preliminary 2016 clinical quality improvement data for 22 rural health care systems participating in an Accountable Care Organization (ACO) for two years. Findings show rural hospitals and clinicians can improve patient quality of life and boost potential for increased shared savings by implementing integrated population health strategies under Caravan Health’s ACO model.

According to the results representing more than 250,000 Medicare beneficiaries, Caravan Health ACOs demonstrated improvements on all but two of the 17 ACO quality measures reported in both 2015 and 2016. Within one year of ACO participation, rural providers increased their overall quality score by 15 percent.

Highlights in preventative health include more patients receiving lifesaving vaccines and screenings such as influenza vaccine up by 48%, fall screenings up by 43%, depression screenings increased by 23%, and pneumonia vaccinations for older adults up by 18%. Utilization data shows a corresponding decrease in bacterial pneumonia admission rates for attributed beneficiaries, suggesting a possible correlation with the increase in vaccinations.

“Rural patients and providers face distinct barriers to improving care in their communities. It is very encouraging to see this kind of progress in such a short amount of time. The data shows that Caravan Health’s ACO model is working for these patients,” said Rayna Caplan, MPH, Caravan Health Director of Population Improvement. “We assess each practice’s current quality measure performance, identify care gaps and pinpoint exactly where their workflows need improvement and optimization. Our delivery team works with practices monthly on coaching and implementation of best practices.”

To effectively manage high-risk, high-cost patients, ACO participants hire a Caravan Health-trained and certified, nurse-level care coordinator to provide support to beneficiaries that need help controlling chronic diseases like Diabetes. As a result, these communities realized a six percent increase from 2015-2016 in the Hemoglobin A1c control measure, meaning that more patients kept their blood sugars stable and avoided unnecessary hospitalizations.

“Our model heavily emphasizes preventive care which is a large contributing factor to the quality improvement success,” said Paul Krause, MD, Caravan Health Chief Medical Officer. “The annual wellness visit (AWV) addresses 11 clinical quality measures in a single visit. To leverage this, we help providers integrate a team-based AWV workflow. Nurses or medical assistants partner with providers to perform or set-up these visits, as appropriate. This maximizes efficiency, more than doubles completion rates and generates additional revenue.”

Based on Caravan Health’s analysis of 2016 clinical quality results from over 150 current communities in 23 ACOs, estimated MIPS quality scores are projected to be between 80-97%. This positions all eligible clinicians in these ACOs to receive an upward adjustment on their Part B payments in 2019 under MIPS.

While measure rates are up, lots of unmet need remains in rural areas, especially in the area of behavioral health. Less than half of those with a depression diagnosis receive appropriate care. To help address and combat this growing issue, Caravan Health is introducing a new psychiatric collaborative care model that gives rural providers access to a psychiatrist to best serve patients in need.

“In one year, our rural providers have drastically improved their care delivery,” said Dr. Krause. “We look forward to continuing to strengthen the rural health system through the ACO model, and helping providers improve their quality of care, while lowering costs and generating savings.”

Lynn Barr, MPH, Caravan Health CEO, along with Rayna Caplan, MPH, will present a one hour webinar about the clinical data on Wednesday, August 9 at 10:00am PT/12:00pm CT/1:00pm ET. The webinar will feature presenters from the participating ACOs, where they will discuss strategies employed to strengthen their delivery systems.

To join the webinar, please register via the WebEx line here. Dial-in information: 1-240-454-0879, access code: 802 435 015.

For more information about Caravan Health and its services, visit

About Caravan Health:
Caravan Health helps providers implement population health programs with affordable, end-to-end solutions that achieve outstanding results.



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