Ensuring that our patients get efficient and effective care across the continuum requires a strong partnership with the communities we serve. Kari Evans, Post-Acute Care (PAC), Transitions of Care (TOC) Nurse for Dignity Health’s Care Coordination team in Arizona, has been working hard in her community to do this by addressing hospital capacity and placement challenges. Here we share just a few of the wins on her impressive list of accomplishments this year.

Managing Hospital Capacity

In April, Evans was asked to meet with the Arizona Surge Line, Arizona’s COVID Patient Transfer Center Line, and Dr. Lisa Villarroel, Medical Director of Public Health Preparedness, to share challenges hospitals are facing regarding bed capacity and post-acute placement to help them expand the Surge Line and address these capacity issues. During the meeting, Evans shared several key post-acute barriers to placement, including:

●  A communitywide lack of information regarding who can take patients with COVID.
●  Limited capacity of facilities willing to take COVID patients.
●  A lack of clarity around current requirements, leading to poor placement options and increased length of stay. 
●  A time-consuming manual process that required weekly surveys and phone calls.

Based on this groundwork, a task force was created, which Evans worked on to help develop a variety of programs and initiatives, including:

●  A Post Acute Care Capacity Tracker (PACCT) using GIS technology to help identify post-acute facilities throughout the state accepting COVID patients. The tracker now has over 250 facilities and agencies documenting daily COVID active and COVID recovered capacity and admission requirements.
●  Providing information that led to Governor Executive Orders written to assist with throughput, consistency on SNF COVID admissions/isolation criteria, and a requirement to enter data into the PACCT database daily.
●  Educating Leadership Teams on the PACCT dashboard to assist with COVID discharges and manage the dashboard access for the local market.
●  Participating in weekly calls with the physician leaders from ADHS and other key post-acute leaders to share continued hospital discharge challenges and post-acute placement needs that led to new projects and Governor Executive Orders.
●  Escalating challenging post-acute facilities to ADHS key leaders, who could then investigate and provide education to facilities that were refusing to take their residents back or enforcing extreme requirements.

Supporting a SNF Pilot

Evans assisted with a COVID capacity pilot project which allowed Dignity Health to place patients needing SNF level of care who were still in their isolation period (10-20 days) but stable for discharge, bypassing some of the red tape that most SNFs require for COVID admissions. Evans helped implement the pilot, provided ADHS with feedback, and engaged and educated Dignity Health Care Coordination teams on the project, which has been expanded to all hospitals statewide.

Aiding in Disaster Planning

Evans also aided in disaster planning at the local level, including:

●  The Apria DME surge plan, a plan to have oxygen vans at each campus to allow liaisons to restock oxygen to expedite discharges and open bed capacity sooner during the surge in late June and early July.
●  HSAG weekly calls, to provide updates on our challenges and efforts at the hospital level, and ways our post-acute teams could assist with the challenges.
●  Weekly Incident Command calls, providing updates for the East Valley Hospitals regarding ongoing barriers and solutions.

“Kari has done some incredible work in the last six months in the community with PAC and the state surrounding COVID,” says Barbara Brownell, MSW, Director of Post-Acute Care Operations, Care Coordination, at Dignity Health. “We appreciate her dedication to advocating on our behalf and to ensuring our patients receive the care they need when they need it most.”

The sprawling geography of the ND/MN region presents a unique obstacle: The miles and hours of travel time between sites — many of them in rural areas — make cohesion and collaboration challenging.

The closest site to the Fargo division office is an hour away, the furthest is six hours away, and most sites have at least a two-hour drive between them. But the region is working to bridge these gaps and move toward a value-based model. Here’s how:

1. Taking the leap into value-based care. They started by working with Blue Cross Blue Shield’s Blue Alliance program, a venture into value-based care with a non-risk model that’s appropriate for their smaller facilities, many of which are critical-access hospitals.

2. Finding ways to connect and standardize. By using a regional occupational health network and the SYSTOC EMR software, they’ve linked patients to primary care across large rural areas.

3. Making communication a priority. Driving strategy across such a broad market takes communication at every level, and they work to ensure it’s happening. That requires physicians and front-line staff in the remote offices talking to one another as well as using one-on-ones with managers to transfer information.

Reaping the rewards

Their efforts are already garnering results, including:

• Childhood immunizations for 0 to 3 increased 17 percent to 93 percent.
• Mammography rates climbed from in the 40th percentile to above the 90th percentile.
• Well-child visits for children over 3 rose above the 90th percentile.
• One site was on the state’s honor roll for wellness visits and immunizations, including adult immunizations.

“We see the future of value-based programming on a rural level, and we’ve really been able to start optimizing that,” says Marvin Smoot, ND/MN Division president for the Physician Enterprise. “We’re starting to align our system in a way that we never have.”

Providing population health and care management serving employer contracts has been critical to Arkansas Health Network’s (AHN) success. In 2018, AHN launched a industry unique partnership with Arkansas Children’s Care Network (ACCN), and statewide pediatric Clinically Integrated Network (CIN) designed to drive a Direct-to-Employer (DTE) strategy that positively impacts employee health, increases productivity and generates cost savings.

AHN’s exclusive collaboration agreement with ACCN focuses on improving care for both children and adults, helping employees and employers navigate the health care system by providing tools and resources, and engaging them in programs and activities to help them achieve better health.

Anthony Timberlands Inc. is a recent example of this employer group strategy in action. In 2018, AHN partnered with the wood products and timberland management company to help curb health care costs and improve the health of approximately 1,000 employees in its plan. Since then, the company has seen its healthcare claims drop significantly as patients with conditions like extreme hypertension and diabetes were caught early and treated. Read more in this Arkansas Business profile.

Because health care can be complicated for employers to navigate, AHN worked to make it easier for employers to see the big picture by developing an engaging four-minute video. The video provides potential employer and broker clients with a quick, easy-to-understand overview of the AHN and ACCN organizations, their population-health-driven model, and all the benefits their members and company can expect to enjoy.

All of these combined efforts are paying off for the network. In 2018, AHN saved $1.29 million for the CHI St. Vincent Employee Health Plan and was awarded nearly $1 million for successfully managing the QualChoice Advantage Value-Based Care contract’s Quality Improvement Program.

In total, AHN and ACCN are working together for five employer clients in Arkansas with plans to continue expanding in 2021.

Moving from fee-for-service to a value-based model requires experienced and dynamic leadership, and Arkansas Health Network (AHN) has found this vital expertise in its exemplary board of managers. Under their skillful guidance, the physician-driven network has seen its focus on quality measures yield enhanced care and millions in shared savings.

“For the last five to six years, they have been instrumental in guiding AHN through the journey of value-based care,” says Bob Sarkar, AHN’s president and CEO. “Their contribution to AHN’s repeated success has been one of our key foundational building blocks.”

The board of managers is comprised of independent practice physicians, CHI St. Vincent-employed physicians, administrative leaders and community representatives. Board members include:

David Foster, M.D.
Daniel Felton, M.D.
David Griffen, M.D.
Srinivasan Ramaswamy, M.D.
William McColgan, M.D.
John Meadors, M.D.
David Coussens, M.D.
Kyle Roper, M.D.
B. Brooks Lawrence, MD
Bob Sarkar
Nutan Bhaskar, M.D.
J.P. Wornock, M.D.
John Jones, M.D.
Lisa Sajovitz, M.D.

Part of achieving our goals requires going beyond our walls and working with others to advocate for conditions that will help ensure our success. Natasha Jivani, Director of Payment Innovation and Interim Executive Director for San Joaquin Quality Care Network (SJQCN), offers a perfect example of this work through her recent appointment to serve as a member of the National Association of Accountable Care Organizations (NAACOS) Policy Committee. NAACOS represents more than 12 million beneficiary lives through hundreds of organizations participating in population health-focused payment and delivery models in Medicare, Medicaid and commercial insurance.

Natasha will serve a two-year term on the Policy Committee, which is designed to help guide the NAACOS advocacy agenda to improve the long-term stability and success of the accountable care model. As a committee member, she will provide vital feedback to NAACOS staff on a variety of issues related to the accountable care model, including proposed regulations and legislation under consideration by the U.S. Department of Health and Human Services and Congress, and participate in related advocacy activities.

Our enterprise is honored to have Natasha bring her perspective and represent us on this important committee.

Tanya Wilkinson is a force to be reckoned with at Arizona Care Network (ACN). In fact, in the nearly three years she’s been there, the Executive Director of Clinical Services has developed two critical initiatives that help ACN achieve its goals.

“She was the genius behind the creation of our population health model,” says her colleague, Executive Director of Marketing Debra Stevens.

It is often difficult to prioritize a patient population over 300,000. ACN’s model uses predictive analytics to identify the most complex patients who are at highest risk for deteriorating health, and assign those patients to care coordinators. These care coordinators then reach out to these patients to ensure they receive the education and resources they need for successful self-management. Additionally, our care teams ensure our patients are seen regularly by their ACN primary care provider.

“Tanya created a model where our team engages with the patient, in their treatment settings, their home, or virtually, immediately after being discharged from the hospital to ensure a smooth transition of care from one setting to another,” Debra says. The care team assigned to these patients may include an RN Care Coordinator, Social Worker, and/or Navigator who work in tandem with the primary care provider to facilitate post discharge follow-up as well as continuity of care.” Under Medicare rules, patients must be seen by their primary care provider within three days of being discharged, which can be challenging because their PCP may not always know when they’ve been discharged.

“I think that’s really brilliant, and it has helped reduce readmissions, which is a focus not only for accountable care organizations but for hospitals as well,” Debra says. “And it has improved the health and reduced the total cost of care for our most vulnerable patients.”

A strategist and leader

Tanya was also the chief architect of ACN’s provider rewards program (PRP). One of the keys to ACN’s success has been the intentional aligning of all incentives—for value-based contracts, providers and patients. At the provider level, physicians who see Medicare and Medicaid patients can earn a financial incentive (a quarterly bonus) from ACN for their performance. The PRP gives the network insight into how it can help providers focus on the metrics that matter most.

Tanya’s team also thinks she’s pretty great.

“She’s a compassionate nurse, but it’s her straightforward, transparent leadership style that’s most appreciated by the managers who report to her,” Debra says. “They always know what she’s thinking, and she shares information generously with her team so that they can do their best work. She truly supports them.”

Tanya’s heroic performance at work is rivaled only by her role as a caregiver at home. She is a mother to six children. ACN is fortunate to have her at the helm of one of their most critical teams!