Caravan Health: Spotlighting Best Practises

Reid Health implements a successful Behavioural Health Integration Program

Caravan Health

Reid Health (Reid) serves Richmond’s extended communities and has been part of Caravan Health’s Crouse/Pathways Collaborative ACO since 2015. Reid’s Behavioral Healthcare Integration (BHI)program has been recognized for its effectiveness and patient engagement. Britany Swallow is Reid’s Behavioral Health coordinator. April Coffin, Director Outpatient Behavioral Health has also been involved in ensuring that patients have all the support they need, while working with staff to reach their goals. Seven may be Reid’s lucky number.

Chambers Health Enhances Patient Outcomes By Using HCC Coding

Caravan Health

Chambers Health operates a critical access hospital in Anahuac, Texas and two FQHCs in Belview, Texas. Recognizing the unpredictable nature of health care and the desire to improve patient care, providers and staff set out to treat the whole patient and not just the symptoms.

Comprehensive patient outcomes became a priority. They reviewed key performance indicators and Caravan Compass reports. Then they worked closely with Caravan partners to find gaps in care. To reduce the gap between coders and medical teams, it was clear that HCC coding could be more important. This would allow for better value-based care. The Chambers staff worked closely with Caravan Health to transition to a level that put improved HCC Coding at the top of their patient care priorities.

Tri-State Memorial Hospital uses quality data to build a successful chronic care management program

Tri-State Memorial Hospital, (TSMH), is a critical-access hospital that provides primary care and specialty services to residents of Clarkson, Washington, and Lewiston in Idaho. Caravan Health partnered with physicians and staff to create a program for chronic care management (CCM). They sought to improve preventive services, manage disease better, and engage patients. Nicole Louchart, RN was recruited to help develop the program. Her unique approach to enhancing the program was what she brought to TSMH when she joined.

Helen Newberry Joy Hospital Nurses Improve Care & Impact Social Determinants

After the Caravan Health PHN training in communication styles, Andrea Marsh, Population Health Nurse, was able to apply her new skills to a difficult patient situation. Her experience was with a complex patient with complex medical needs, who was part of an underserved and disadvantaged family. It was presumed that the daughter was the most capable person to disseminate and receive written instructions throughout their entire care history. Andrea noticed inconsistent follow-through from the daughter, despite her being a good listener. Andrea learned that the family spokesperson couldn’t read after having more conversations with her extended family.