Notes and Disclaimers:
- Projects shown may also have operated 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 were 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.
DENVER HEALTH AND HOSPITAL AUTHORITY
Project Title: “Integrated model of individualized ambulatory care for low income children and adults”
Geographic Reach: Colorado
Funding Amount: $19,789,999
Estimated 3-Year Savings: $12,792,256
Summary: The goal of the project is for Denver Health to transform its primary care delivery system to provide individualized care to more effectively meet its patients' medical, behavioral and social needs. This model provides team-based care, coordinates care across health settings and offers self-care support between visits enabled by health information technology (HIT) and team-based patient navigators who reach out to patients in a variety of ways. It also integrates physical and behavioral health services in collaboration with the Mental Health Center of Denver (MHCD) in existing primary care settings and in newly created high-risk clinics for the most complex patients. Over the three-year grant period, Denver Health’s 21st Century Care program will ensure increased access to care by 15,000 people, improve overall population health for Denver Health patients by 5 percent, improve patient satisfaction with care delivered between visits by 5 percent without decreasing satisfaction with visit-based care, and decrease total cost of care by 2.5 percent relative to trend.
INSTITUTE FOR CLINICAL SYSTEMS IMPROVEMENT
Project Title: "Care management of mental and physical co-morbidities: a TripleAim bulls-eye"
Geographic Reach: California, Colorado, 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 received 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.
RUTGERS, THE STATE UNIVERSITY OF NEW JERSEY (THE CENTER FOR STATE HEALTH POLICY)
Project Title: "Sustainable high-utilization team model”
Geographic Reach: California, Colorado, Missouri, Pennsylvania
Funding Amount: $14,347,808
Estimated 3-Year Savings: $67,719,052
Summary: Rutgers, The State University of New Jersey, received an award to expand and test a team-based care management strategy for high-cost, high-need, low-income populations served by safety-net provider organizations in Allentown, PA, Aurora, CO, Kansas City, MO, and San Diego, CA. Led by Rutgers Center for State Health Policy, the project will use integrated care management teams (including nurses, social workers, and community health workers) to provide clients with patient-centered support that addresses both health care needs and the underlying determinants of health. Teams will assist patients in managing chronic illness, including filling prescriptions and coordinating appropriate specialty care, in addition to addressing social service needs such as identifying stable housing, applying for health coverage or disability benefits and facilitating transportation arrangements. After patients are stabilized, the care management team will transition them to local primary care medical homes. By improving beneficiaries’ access to ambulatory medical and social services, the project will improve patient outcomes and reduce preventable hospital inpatient and emergency room utilization. Over a three-year period, Rutgers’s program will create an estimated 43 jobs across multiple health care professions.
SOUTHEAST MENTAL HEALTH SERVICES
Project Title: "TIPPING POINT: Total Integration, Patient Navigation and Provider Training Project for Powers County, Colorado"
Geographic Reach: Colorado
Funding Amount: $1,405,924
Estimated 3-Year Savings: $1,875,000
Summary: Southeast Mental Health Services received an award to coordinate comprehensive, community-based care for high-risk, high-cost, and chronically ill residents of rural Prowers County, Colorado. The program employs Bachelor-level trained patient navigators to increase patients' access to primary and behavioral care, preventive care, and early intervention services, offering team-based education and coaching to improve both population health and self-management of disease. The results will include a reduction in emergency room visits and other high cost interventions, mitigation of the progress of chronic disease, better health habits, and better care and quality of life for these vulnerable patients. Southeast Mental Health Services is contracting with Otero Junior College to provide a “Health Navigator” training program to serve current and future healthcare workers across rural Colorado. Over a three-year period, Southeast Mental Health Service's program will train an estimated 62 workers and create an estimated 8.25 FTE jobs. The new workers will include health navigators, instructors, a marketing/communications assistant, and a project manager.
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: Colorado, Florida, Kansas, Texas
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 developing and testing the Brookdale Senior Living 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 skilled nursing facilities in Florida, Colorado, Kansas and Texas. 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 Brookdale Senior Living Transitions of Care program will train an estimated 10,926 workers and create an estimated 97 jobs for clinical nurse leaders and other health care team members.
UPPER SAN JUAN HEALTH SERVICE DISTRICT
Project Title: "Southwest Colorado cardiac and stroke care”
Geographic Reach: Colorado
Funding Amount: $1,724,581
Estimated 3-Year Savings: $8,100,000
Summary: The Upper San Juan Health Service District is improving care for cardiovascular disease and risk through a multifaceted approach in order to reduce costs and to improve the quality of care in rural and remote areas of southwestern Colorado. The care delivery model will offer cardiovascular early detection and wellness programs, implement a telemedicine acute stroke care program, use telemedicine and remote diagnostics for cardiologist consultations, and upgrade and retrain its Emergency Medical Services Division staff to manage urgent care transports and in-home follow-up patient care for patients in medically underserved areas in Southwest Colorado. A cardiovascular patient navigator integrates care through the continuum and assists in removing barriers, resulting in better care through all phases of the intervention. The program will provide access to cardiologists and neurologists and is expected to reduce cardiovascular risk, improve patient outcomes, create healthier communities, and reduce health care costs with estimated savings of approximately $8.1 million. Over the three-year period, the Upper San Juan Health Service District’s program will train an estimated 25 paramedics and telehealth clinicians and create 13 new jobs. These workers will provide a new type of clinical team that will improve care outcomes for rural cardiovascular patients.