Building Blocks of Population Health by the Numbers

Earlier this year, Caravan Health launched their podcast Health Care by the Numbers to explore the numbers driving change throughout the health care industry. In case you missed the second season, the podcast topics focused on the building blocks of population health and highlighted the outstanding work of their clients at a variety of health systems across the country. Take a listen to season two.

Episode 1: Success of the ACO Investment Model with Amy McDaniel, Chief Executive Officer at Iowa Specialty Hospitals & Clinics in IA, and Steve Barnett, President & CEO at McKenzie Health System in Sandusky, MI. Caravan is proud of our leadership role in the ACO Investment Model, one of the most successful alternative payment models operated by CMS. Host Greg Paris talks with these two AIM participants about the history of health care reform and how the movement has matured from volume-driven, fee-for-service delivery toward value-based care. The guests explain how care management, especially between sites of care, has truly transformed care and made all the difference in rural ACO success. Working with Caravan has allowed small health systems to increase patient volume through practice transformation and population health. The conversation also touches on the anticipated CHART ACO model, which will bring this transformation to even more rural practices in 2023.

Episode 2: Physician Contracting with Shawn Rhodes, Director of Clinical Integration at Med Center Health, in Bowling Green, KY. Todd Searls and co-host Dr. Ashok Roy lead the conversation around the importance of physician contracting in establishing a thriving value-based system. Engaging physicians and implementing an intentional team-based approach can have positive effects on rates of burnout and improve staff retention. The podcast discusses promising avenues for medical education and structuring compensation to incentivize participation, especially in rural areas. Since the podcast, Shawn has joined Caravan Health as a Regional Vice President.

Episode 3: Behavioral Health Integration with Britany Swallow and April Coffin from Reid Health in Richmond, Indiana.  In this episode, co-hosts Louise Yinug and Wei-Lin Huang talk with the experts at Reid Health about coordination of primary care and behavioral health services. As the need for mental health services surges with the ongoing pandemic and social stressors, Reid Health has made great strides in identifying patients needing services and getting them the help they need.

Episode 4: HCC coding with Beth Mindt and Dr. Rajohn Karanjai from Sidney Health Center in Sidney, Montana. Todd Searls and co-host Jade Jagers discuss how HCC coding is critical to ACO success. Sidney Health Center has focused on improving communication among providers, coders, and IT specialists to get proper compensation for the care delivered. Caravan reinforces the importance of HCC at all opportunities, including regular roadmap calls and steering committee conversations. Dr. Karanjai maintains an ongoing conversation with his staff, reminding them that change won’t happen overnight but an engaged approach to team-based care and HCC coding will pay off.

Episode 5: Advance Care Planning with Nikki Rabehl, Carrie Kranz, Tricia Schilling, and Emily Goldman from Olmsted Medical Center in Rochester, Minnesota. Todd Searls and co-host Kim Morgan talk about the importance of documenting patients’ health care wishes. This requires building relationships between patients and providers, as it often starts with a difficult conversation about end-of-life care. The COVID pandemic did not stall or slow down this work but made it all the more real for patients and families. The podcast guests discuss how care managers relied on each other to maintain critical primary care services through the challenges of the public health emergency.

Episode 6: Telehealth and virtual care with Alcona Health Center in northern MI. Todd Searls and Regional Vice President David Latzer interviewed Susan Hoes and Bernie O’Brien about how they pivoted to telehealth and virtual care at the beginning of the COVID public health emergency. Their conversation touches on the challenges they faced, such as equipment shortages and patient unfamiliarity with some of the technology. Alcona overcame these challenges and was able to introduce interventions such as screening staff at the front door to manage the new and evolving situation.

Join us for Season 3 of Health Care by the Numbers featuring Caravan leaders like Nicole Banister, Senior VP of Practice Transformation and Sue Dietz, VP of Business Development. Episodes available at and at Healthcare NOW Radio.

This article was originally published on the Caravan Health blog and is republished here with permission.