Notes and Disclaimers:
- Projects shown may also be operating in other states (see the Geographic Reach)
- Descriptions and project data (e.g. gross savings estimates, population served, etc.) are 3 year estimates provided by each organization and are based on budget submissions required by the Health Care Innovation Awards application process.
- While all projects are expected to produce cost savings beyond the 3 year grant award, some may not achieve net cost savings until after the initial 3-year period due to start-up-costs, change in care patterns and intervention effect on health status.
ATLANTIC GENERAL HOSPITAL CORPORATION
Project Title: “Expand Atlantic General Hospital’s infrastructure to create a patient-centered medical home”
Geographic Reach: Maryland
Funding Amount: $1,097,512
Estimated 3-Year Savings: $3,522,000
Summary: Atlantic General Hospital Corporation, which serves largely rural Worcester County, Maryland, is receiving a grant to improve care for Medicare beneficiaries with either a primary or admitting diagnosis of congestive heart failure, chronic obstructive pulmonary disease, or diabetes, who currently rely on high cost ER visits and Acute Care admissions. The corporation plans to expand infrastructure and create a Patient-Centered Medical Home, increasing access for patients needing non-emergency episodic care and reducing hospital admission rates and emergency department visits for these Medicare beneficiaries.
Over a three-year period, Atlantic General Hospital Corporation will create three new jobs and train 75 workers. New hires will include a patient care manager, a patient advocate, and a care team coordinator.
Project Title: "Medicare and CareFirst’s total care and cost improvement program in Maryland”
Geographic Reach: Maryland
Funding Amount: $24,000,000
Estimated 3-Year Savings: $29,213,838
Summary: CareFirst BlueCross/BlueShield is receiving an award to expand its Total Care and Cost Improvement Program (TCCI), a Patient-Centered Medical Home model of care delivery and payment, to 25,000 Medicare beneficiaries in Maryland per year. This approach will move the region toward a new health care financing model that is more accountable for care outcomes and less driven by the volume-inducing aspects of fee-for-service payment. The TCCI model will enhance support for primary care, empowering primary care physicians to coordinate care for multi-chronically ill Medicare beneficiaries and patients at high risk for chronic illnesses. TCCI will result in less fragmented health care, reducing avoidable hospitalizations, emergency room visits, medication interactions, and other problems caused by gaps in care and ensuring that patients receive the appropriate care for their conditions.
Over a three-year period, the CareFirst BlueCross/BlueShield program will train an estimated 672 workers and will create an estimated 28 jobs. The new workforce will include local care coordinators, specialty-based nurse case managers, hospital transition of care coordinators, program consultants, pharmacy managers, clinical pathways hub operations and support workers, operational and data support positions.
GEORGE WASHINGTON UNIVERSITY
Project Title: "Using Telemedicine in peritoneal dialysis to improve patient adherence and outcomes while reducing overall costs”
Geographic Reach: District of Columbia, Maryland, Pennsylvania, Virginia
Funding Amount: $1,939,127
Estimated 3-Year Savings: $1,700,000
Summary: George Washington University is receiving an award to improve care for about 300 patients on peritoneal dialysis in Washington, D.C., and eventually in Philadelphia and Southern Maryland. The intervention will use telemedicine to offer real-time, continuous, and interactive health monitoring to improve patient safety and treatment. The model will train a dialysis nurse workforce in prevention, care coordination, team-based care, telemedicine, and the use of remote patient data to guide treatment for co-morbid, complex patients. This approach is expected to improve patient access to care, adherence to treatment, self-management, and health outcomes, reducing cost of care for peritoneal dialysis patients with complex health care needs by reducing overall hospitalization days with estimated savings of approximately $1.7 million. Over the three-year period, George Washington University’s program will train an estimated three health care workers and create an estimated three new jobs. These workers will provide clinical support and health monitoring via the web to home dialysis patients.
JOHNS HOPKINS SCHOOL OF NURSING
Project Title: "CAPABLE for frail dually eligible older adults: achieving the triple aim by improving functional ability at home”
Geographic Reach: Maryland
Funding Amount: $4,093,356
Estimated 3-Year Savings: $6,800,000
Summary: The Johns Hopkins School of Nursing is receiving an award for a Medicare/Medicaid dual eligibles program (Community Aging in Place, Advancing Better Living for Elders –“CAPABLE”) that uses a care management team to improve the everyday functioning of complex, frail patients in their own homes. The program will reduce difficulty with activities of daily living and improve medication management, mobility, and health-related quality of life, based on an individualized package of interventions including home visits from occupational therapists and nurses and other services. CAPABLE will reduce nursing home admissions and hospitalizations and improve quality of life for these beneficiaries of Medicare and Medicaid.
Over a three-year period, the John Hopkins School of Nursing will retrain an estimated eight occupational therapists and registered nurses and as well as engage other services.
JOHNS HOPKINS UNIVERSITY
Project Title: "Johns Hopkins Community Health Partnership (J-CHiP)"
Geographic Reach: Maryland
Funding Amount: $19,920,338
Estimated 3-Year Savings: $52,600,000
Summary: Johns Hopkins University -- in partnership with Johns Hopkins Health System and its hospitals, community clinics and other affiliates; the Johns Hopkins Urban Health Institute; Priority Partners MCO; Baltimore Medical System, a Federally Qualified Health Center; and local skilled nursing facilities, is receiving an award to create a comprehensive and integrated program, the Johns Hopkins Community Health Partnership (J-CHiP). J-CHiP is designed to increase access to services for high-risk adults in East Baltimore, MD, especially those with chronic illness, mental illness, and/or substance abuse conditions. The intervention improves care coordination across the continuum and comprises early risk screening, interdisciplinary care planning, enhanced medication management, patient/family education, provider communication, post-discharge support and home care services, including self-management coaching, and improved access to primary care. The program will target inpatients at The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center, expanding to nearly all admissions by year 3. The intervention will also include a specific focus on high risk Medicare and Medicaid beneficiaries who receive primary care from Johns Hopkins providers in the seven zip code area adjacent to these hospitals. The program will reduce avoidable hospitalizations, emergency room use, and complications and increase access to care and other services.
Over a three-year period, Johns Hopkins University will train and hire 111 new health care workers, including patient/family educators, care coordinators, and behavioral coaches, and will retrain nurse case managers, nurse transition guides, nurse screeners, pharmacists, and physicians already on staff.
SAN FRANCISCO COMMUNITY COLLEGE
Project Title: "Transitions clinic network: linking high-risk Medicaid patients from prison to community primary care”
Geographic Reach: Alabama, California, Connecticut, District of Columbia, Maryland, Massachusetts, New York, Puerto Rico
Funding Amount: $6,852,153
Estimated 3-Year Savings: $8,115,855
Summary: The San Francisco Community College District (City College of San Francisco), in partnership with the University of California San Francisco and Yale University, is receiving an award to address the health care needs of high-risk/high-cost Medicaid and Medicaid-eligible patients released from prison, targeting eleven community health centers in six states, The District of Columbia, and Puerto Rico. The program will work with the Department of Corrections to identify patients with chronic medical conditions prior to release and will use community health workers trained by City College of San Francisco to help these individuals navigate the care system, find primary care and other medical and social services, and coach them in chronic disease management. The outcomes will include reduced reliance on emergency room care, fewer hospital admissions, and lower cost, with improved patient health and better access to appropriate care.
Over a three-year period, the San Francisco Community College District's program will create an estimated 12.3 jobs and train an estimated 53.7 workers. The new workforce will include 7 community health workers, 11 part-time panel managers, 2 part-time project coordinators, one research analyst and two part-time project staff.