Notes and Disclaimers:
- Projects shown may have also 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.
BEN ARCHER HEALTH CENTER
Project Title: “A home visitation program for rural populations in Northern Dona Ana County, New Mexico”
Geographic Reach: New Mexico
Funding Amount: $1,270,845
Estimated 3-Year Savings: $6,325,888
Summary: Ben Archer Health Center in southern New Mexico has implemented an innovative home visitation program for individuals diagnosed with chronic disease, persons at risk of developing diabetes, vulnerable seniors, and homebound individuals, as well as young children and hard to reach county residents. Ben Archer Health Center provides primary health, dental, and behavioral health care to rural Doña Ana County, a medically underserved and health professional shortage area. The Ben Archer Health Center's Health Care Innovation Award uses nurse health educators and community health workers to bridge the gap between patients and medical providers, aid patient navigation of the health care system, and offer services including case management, medication management, chronic disease management, preventive care, home safety assessments, and health education, thereby preventing the onset and progression of diseases and reducing complications. Project staff provides diabetes and asthma management classes for patients and families. The project implements a culturally-appropriate, immunization methodology utilizing door-to-door outreach campaigns. The staff connects individuals with primary care homes to decrease the cost of complications caused by disease in the predominately Hispanic population.
FEINSTEIN INSTITUTE FOR MEDICAL RESEARCH
Project Title: “Using care managers and technology to improve the care of patients with schizophrenia”
Geographic Reach: Florida, Indiana, Michigan, Missouri, New Hampshire, New Mexico, New York, Oregon
Funding Amount: $9,380,855
Estimated 3-Year Savings: $10,080,000
Summary: The Feinstein Institute for Medical Research received an award to develop a workforce that is capable of delivering effective treatments, using newly available technologies, to at-risk, high-cost patients with schizophrenia. The intervention will test the use of care managers, physicians, and nurse practitioners trained to use new technology as part of the treatment regime for patients recently discharged from the hospital at community treatment centers in eight states. These trained providers will educate patients and their caregivers about pharmacologic management, cognitive behavior therapy, and web-based/home-based monitoring tools for their conditions. This intervention is expected to improve patients’ quality of life and lower cost by reducing hospitalizations. Over a three-year period, the Feinstein Institute for Medical Research will retrain nurse practitioners, physician assistants, physicians, and case managers to use newly available mental health protocols and health technology resources.
INNOVATIVE ONCOLOGY BUSINESS SOLUTIONS, INC.
Project Title: “Community oncology medical homes (COME HOME)”
Geographic Reach: Florida, Georgia, Maine, New Mexico, Ohio, Texas
Funding Amount: $19,757,338
Estimated 3-Year Savings: $33,514,877
Summary: Innovative Oncology Business Solutions, Inc., representing 7 community oncology practices across the United States received an award to implement and test a medical home model of care delivery for newly diagnosed or relapsed Medicare and Medicaid beneficiaries and commercially insured patients with one of the following seven cancer types: breast, lung, colon, pancreas, thyroid, melanoma and lymphoma. Cancer care is complicated, expensive, and often fragmented, leading to suboptimal outcomes, high cost, and patient dissatisfaction with care. Through comprehensive outpatient oncology care, including extended clinic hours, patient education, team care, medication management, and 24/7 practice access and inpatient care coordination, the medical home model will improve the timeliness and appropriateness of care, reduce unnecessary testing, and reduce avoidable emergency room visits and hospitalizations. Over a three-year period, Innovative Oncology Business Solutions will fill 115.6 new health care jobs, including positions for training specialists, data analysts, patient care coordinators, registered nurses, and licensed practical nurses, as well as for a finance manager and a compliance manager.
UNIVERSITY OF NEW MEXICO HEALTH SCIENCES CENTER
Project Title: “Leverage innovative care delivery and coordination model: Project ECHO”
Geographic Reach: New Mexico
Funding Amount: $8,473,809
Estimated 3-Year Savings: $11,100,000
Summary: The University of New Mexico Health Sciences Center is receiving an award for its ECHO Project. The goals of the ECHO® model is to improve the quality of care and reduce the total cost by at least 3.5% in 2,500 high-need, high-cost Medicaid beneficiaries in New Mexico, and to increase overall primary care capacity to diagnose and provide the best treatment for these complex patients. The ECHO Care™ program will expand the capacity of the primary care workforce through participation in a TeleECHO™ clinic dedicated to co-managing complex care for patients with significant multi-morbidity, including mental health and substance abuse. In addition to this new Complex Care teleECHO Clinic, a new type of primary care clinical team will care for these patients with complex medical, behavioral and social needs at provider sites located around New Mexico. This “outpatient intensivist team” (OIT), has the potential to dramatically improve care and reduce costs for the Medicaid beneficiaries experiencing high utilization of services.
Medicaid has been an active partner with ECHO Care™ from its inception, and continues to be strongly committed to its success. Multiple Medicaid MCOs will fund the OITs based on the patient population cared for by the OIT at each provider site as well as compensate the multidisciplinary team of specialists at the Complex Care teleECHO Clinic for consultative services.
The high-need and high-cost Medicaid population to be served by ECHO Care™ is being identified through the assistance of researchers at New York University who have developed a methodology to select the most complex and costly patients whose costs can be impacted with comprehensive and coordinated care. Strategies for sustaining these savings beyond the project time period include the maintenance of increased capacity of OITs to manage complex patients and the formulation of a replicable reimbursement model utilizing the ECHO® prototype as a core element of healthcare delivery.
JOSLIN DIABETES CENTER, INC.
Project Title: “Pathways to better health through a new health care workforce and community”
Geographic Reach: District of Columbia, New Mexico, Pennsylvania
Funding Amount: $4,967,276
Estimated 3-Year Savings: $7,400,000
Summary: Joslin Diabetes Center, Inc., received an award to expand a successful program for diabetes education, field testing, and risk assessment. Their “On the Road” program will send trained community health workers into community settings to help approximately 5100 unique participants (most of whom are Medicare/Medicaid beneficiaries and /or low income/uninsured) understand their risks and improve health habits for the prevention and management of diabetes. The program will target at risk and underserved populations in New Mexico, Pennsylvania, and Washington, D.C., helping to prevent the development and progression of diabetes and reducing overall costs, avoidable hospitalizations, and the development of chronic co-morbidities with estimated savings of approximately $7.4 million. Over the three-year period, Joslin Diabetes Center’s program will train an estimated 27 workers, while creating an estimated 9 new jobs. These workers will include community health advocates and health education instructors who will educate patients in managing diabetes and pre-diabetes with the goal of re-engaging them into the healthcare system.