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.
BETH ISRAEL DEACONESS
Project Title: “Preventing avoidable re-hospitalizations: Post-Acute Care Transition Program (PACT)”
Geographic Reach: Massachusetts
Funding Amount: $4,937,191
Estimated 3-Year Savings: $12,900,000
Summary: Beth Israel Deaconess Medical Center (BIDMC) of Boston, Massachusetts, received an award to improve care transitions and reduce hospital readmissions for Medicare beneficiaries and beneficiaries dually eligible for Medicare and Medicaid. By integrating care, improving patients’ transitions between locations of care, and focusing on a battery of evidence-based best practices, this model is expected to prevent complications and reduce preventable readmissions, resulting in better quality health care at lower cost in the urban Boston area with estimated savings of almost $13 million over 3 years.
FOUNDATION FOR CALIFORNIA COMMUNITY COLLEGES
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: City College of San Francisco (CCSF), University of California at San Francisco, and Yale University are collaborating to address the health care needs of high risk/high cost Medicaid and Medicaid-eligible individuals with chronic conditions released from prison. Targeting eleven community health centers in seven states 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 healthcare 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, this innovation will create an estimated 22 jobs and train an estimated 49 workers. The new workforce will include 12 community health workers, 11 part-time panel managers, two part-time project coordinators, one research analyst and two part-time project staff.
HEALTH RESOURCES IN ACTION
Project Title: “New England asthma innovations collaborative”
Geographic Reach: Connecticut, Massachusetts, Rhode Island, Vermont
Funding Amount: $4,040,657
Estimated 3-Year Savings: $4,100,000
Summary: Health Resources in Action is receiving an award for a program of its New England Asthma Regional Council, titled the New England Asthma Innovations Collaborative (NEAIC). NEIAC is a multi-state, multi-sector partnership that includes health care providers, payers, and policy makers aimed at creating an innovative Asthma Marketplace in New England that will increase the supply and demand for high-quality, cost-effective health care services. Over the three year funding period, services will be delivered to over 1400 children ages 2-17 with persistent asthma who have had at least one related emergency department visit, observation stay, hospitalization or received a prescription in the 12 months prior to enrollment. The intervention will lower costs of asthma care by delivering cost-effective prevention oriented care in clinics and at home to reduce preventable pediatric-related emergency department visits and hospital admissions with estimated savings of over $4 million. NEAIC will also train an estimated 64 health care workers, while creating an estimated 17 new jobs. These workers will include well-trained community health workers and asthma educators. Finally, NEAIC will work to sustain these cost-effective services by piloting reimbursement methodologies with payers. In sum, NEAIC will create a new type of workforce and service delivery model that targets cost-effective and culturally competent care, which features patient self-management education, environmental interventions and long-term sustainability payment mechanisms of these services.
INSTITUTE FOR CLINICAL SYSTEMS IMPROVEMENT
Project Title: “Care management of mental and physical co-morbidities: a TripleAim bulls-eye"
Geographic Reach: California, Colorado, Iowa, Massachusetts, Michigan, Minnesota, Pennsylvania, Washington, Wisconsin
Funding Amount: $17,999,635
Estimated 3-Year Savings: $27,693,046
Summary: The Institute for Clinical Systems Improvement (ICSI) of Bloomington, Minnesota is receiving an award to improve care delivery and outcomes for high-risk adult patients with Medicare or Medicaid coverage who have depression plus diabetes or cardiovascular disease. The program will use care managers and health care teams to assess condition severity, monitor care through a computerized registry, provide relapse and exacerbation prevention, intensify or change treatment as warranted, and transition beneficiaries to self-management. The partnering care systems include clinics in ICSI, Mayo Clinic Health System, Kaiser Permanente in Colorado and Southern California, Community Health Plan of Washington, Pittsburgh Regional Health Initiative, Michigan Center for Clinical Systems Improvement, and Mount Auburn Cambridge Independent Practice Association with support from HealthPartners Research Foundation and AIMS (Advancing Integrated Mental Health Solutions).
Over a three-year period, ICSI and its partners will train the approximately 80+ care managers needed for this new model.
Project Title: “Patient-centric electronic environment for improving acute care performance”
Geographic Reach: Massachusetts, Minnesota, New York, Oklahoma
Funding Amount: $16,035,264
Estimated 3-Year Savings: $81,345,987
Summary: The Mayo Clinic, in collaboration with US Critical Illness and Injury Trials Group and Philips Research North America, is receiving an award to improve critical care performance for Medicare/Medicaid beneficiaries in intensive care units (ICUs). Data shows that 27% of such Medicare beneficiaries face preventable treatment errors due to information overload among ICU providers. The Mayo Clinic model will enhance effective use of data using a Cloud-based system that combines a centralized data repository with electronic surveillance and quality measurement of care responses. As a result, Mayo expects to reduce ICU complications and costs.
Over a three-year period, the Mayo Clinic will train 1440 existing ICU caregivers in four diverse hospital systems to use new health information technologies effectively in managing ICU patient care.
Project Title: “Integrating industrial and system engineering (ISE) methods into healthcare improvement"
Geographic Reach: Massachusetts, North Carolina, Washington
Funding Amount: $8,000,002
Estimated 3-Year Savings: $60,780,907
Summary: The Healthcare Systems Engineering Institute at Northeastern University is receiving an award to establish a regional system engineering extension center that will embed proven evidence-based industrial and system engineering (ISE) improvement methods into local healthcare organizations, similar to as used in other complex industries. This demonstration project will launch a network of similar centers across the U.S. to significantly improve care, cost, safety, and quality starting first in Massachusetts, expanding to Washington and North Carolina states during the grant period, and continuing thereafter. Engineers and healthcare professionals will be cross trained in applying these methods to important healthcare problems and work together in engineer-clinician project teams, integrating industrial engineers directly into health systems, establishing internship and summer residency programs, and creating trans-disciplinary curricula for engineers, clinicians, and healthcare managers. The overall goal is to measurably demonstrate the clear value of ISE methods and such a regional extension program, expanded nationally, to significantly lower costs, improve access, and achieve better outcomes, leading to better care and higher patient safety.
Over a three-year period, Northeastern University's program will train an estimated 81 workers in healthcare systems engineering methods and create an estimated 10 new jobs to educate students, oversee applied projects, and manage experiential education.
THE NATIONAL HEALTH CARE FOR THE HOMELESS COUNCIL
Project Title: “Community health workers and HCH: a partnership to promote primary care”
Geographic Reach: California, Florida, Illinois, Massachusetts, Nebraska, New Hampshire, North Carolina, Texas
Funding Amount: $2,681,877
Estimated 3-Year Savings: $1,500,000
Summary: The National Health Care for the Homeless Council is joining into a cooperative agreement to serve ten communities across various regions in the U.S. to reduce the number of emergency department visits and lack of primacy care services for over 1700 homeless individuals. The intervention will integrate community health workers into Federally Qualified Health Centers to conduct outreach and case coordination for transitioning this population from the emergency department to a health center, thus reducing unnecessary emergency department visits and improving quality of care for this population with estimated savings of approximately $1.4million. Over the three-year period, National Health Care for the Homeless Council’s program will train an estimated 101 health care workers, while creating an estimated 17 new jobs. The workers will include community health workers who will conduct outreach and care coordination.
Project Title: “Multi-community partnership between TransforMED, hospitals in the VHA system and a technology/data analytics company to support transformation to PCMH of practices connected with the hospitals and development of “Medical Neighborhood”
Geographic Reach: Alabama, Connecticut, Florida, Georgia, Illinois, Indiana, Kansas, Kentucky, Massachusetts, Michigan, Mississippi, Nebraska, Oklahoma, West Virginia, Wisconsin
Funding Amount: $20,750,000
Estimated 3-Year Savings: $52,824,000
Summary: TransforMED received an award for a primary care redesign project across 15 communities to support care coordination among Patient-Centered Medical Homes (PCMH), specialty practices, and hospitals, creating “medical neighborhoods.” The project will use a sophisticated analytics engine, provided by a vendor, Phytel, to identify high risk patients and coordinate care across the medical neighborhood while driving PCMH transformation in a number of primary care practices in each community. Truly comprehensive care will improve care transitions and reduce unnecessary testing, leading to lower costs with better outcomes. TransforMED will work with VHA to capture learnings from leading performers. Cost trends will be identified via claims data using an analytic tool provided by a vendor, Cobalt Talon. Over a three-year period, TransforMED’s program will train an estimated 3,024 workers and create an estimated 22 jobs.
TRUSTEES OF DARTMOUTH COLLEGE
Project Title: “Engaging patients through shared decision making: using patient and family activators to meet the triple aim”
Geographic Reach: California, Colorado, Idaho, Iowa, Maine, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, New York, Oregon, Texas, Utah, Vermont, Washington
Funding Amount: $26,172,439
Estimated 3-Year Savings: $63,798,577
The High Value Healthcare Collaborative (HVHC) received an award led by The Trustees of Dartmouth College to implement patient engagement and shared decision making processes and tools across its 15 member organizations for patients considering hip, knee, or spine surgery and complex patients with diabetes or congestive heart failure. The program will hire and train 48 health coaches across the 15 member organizations to engage patients and their families in their health care and health decisions.
High Value Healthcare Collaborative (HVHC) is implementing a bundle of services related to the care of sepsis patients across 13 health care systems around the country. The overall goal of this project is to utilize process improvement strategies to implement specific services at 3- and 6-hours post diagnosis as defined by the Surviving Sepsis Campaign (SSC) and National Quality Forum (NQF) guidelines for the care of severe sepsis or septic shock. Over three years, this intervention aims to improve optimal adherence to sepsis bundled care by 5%, reduce the burden of chronic morbidity from sepsis-associated chronic organ dysfunction, and achieve a 5% relative rate reduction in the number of patients with sepsis requiring long-term acute care or sub-acute nursing care after an incident episode of severe sepsis.
UNIVERSITY OF NORTH TEXAS HEALTH SCIENCE CENTER
Project Title: "Brookdale Senior Living (BSL) Transitions of Care Program"
Geographic Reach: Alabama, Arizona, California, Colorado, Connecticut, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Nevada, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Washington, Wisconsin
Funding Amount: $7,329,714
Estimated 3-Year Savings: $9,729,702
Summary: The University of North Texas Health Science Center (UNTHSC), in partnership with Brookdale Senior Living (BSL), is receiving an award to expand and test the BSL Transitions of Care Program which is based on an evidenced-based assessment tool called Interventions to Reduce Acute Care Transfers (INTERACT) for residents living in independent living, assisted living and dementia specific facilities in Texas and Florida. In addition, community dwelling older adults who receive BSL home health services will be included in the Transitions of Care Program. Over the course of the award the program will expand to other states where BSL communities are located. The program will employ clinical nurse leaders (CNLs) to act as program managers. CNLs will train care transition nurses and other staff on the use of INTERACT and health information technology resources to help them identify, assess, and manage residents' clinical conditions to reduce preventable hospital admissions and readmissions. The goal of the program is to prevent the progress of disease, thereby reducing complications, improving care, and reducing the rate of avoidable hospital admissions for older adults.
Over a three-year period, the University of North Texas Health Science Center's program will train an estimated 10,926 workers and create an estimated 97 jobs for clinical nurse leaders and other health care team members.
Project Title: "Using recovery peer navigators and incentives to improve substance abuse Medicaid client outcomes and costs”
Geographic Reach: Massachusetts
Funding Amount: $2,760,737
Estimated 3-Year Savings: $7,841,498
ValueOptions, Inc., with its subsidiary, Massachusetts Behavioral Health Partnership, received an award to test care coordination to reduce repeated utilization of detox services among beneficiaries who have 2 or more detox admissions. With Brandeis University as a research partner, the project uses patient navigators, recovery planning,and behavioral interventions to support member recovery. Four providers will implement the interventions, serving northeastern Massachusetts, southeastern Massachusetts, greater Boston, and the central portion of the state. By linking beneficiaries with appropriate treatment and recovery services, the model will improve their health outcomes, reducing costs by avoiding preventable emergency room visits, hospitalizations and detox readmissions.
Over a three-year period, ValueOptions, Inc.’s program will train an estimated 75 workers and will create an estimated 75 jobs. The new workers will include patient navigators and support staff.
Project Title: "Community-based health homes for individuals with serious mental illness”
Geographic Reach: Massachusetts
Funding Amount: $2,942,962
Estimated 3-Year Savings: $3,792,020
Summary: Vinfen Corporation, in partnership with Bay Cove Human Services, North Suffolk Mental Health Association, Brookline Mental Health Center, Commonwealth Care Alliance, Robert Bosch Healthcare, and Dartmouth University received an award to integrate primary and behavioral health care for individuals with serious mental illness in the metropolitan Boston area. The project embeds Nurse Practitioners, backed by a primary care physician, into existing community based psychiatric rehabilitation and recovery teams, creating community based health homes that provide better care at lower cost for a population at risk for severe chronic disease. Embedded Health Outreach Workers teach participants to manage their behavioral and physical health effectively and more independently. This care team uses telehealth technology to monitor participants’ signs and symptoms, prioritize care and deliver necessary interventions. As a result, the project aims to improve the health of participants, increase their access to primary and specialty health care and reduce the use of costly acute care services.