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.
CENTER FOR HEALTH CARE SERVICES
Project Title: “A recovery-oriented approach to integrated behavioral and physical health care for a high-risk population”
Geographic Reach: Texas
Funding Amount: $4,557,969
Estimated 3-Year Savings: $5,000,000
Summary: The Center for Health Care Services in San Antonio, Texas, received an award to integrate behavioral, mental, and primary health care for a group of approximately 260 homeless adults in San Antonio with severe mental illness or co-occurring mental illness and substance abuse disorders, at risk for chronic physical diseases. Their intervention will integrate health care into existing behavioral health clinics, using a multi-disciplinary care team to coordinate behavioral, primary, and tertiary health care for these people—most of them Medicaid beneficiaries or eligible for Medicaid—and is expected to improve their capacity to self-manage, reducing emergency room and hospital admissions, and lowering cost, while improving health and quality of life and with estimated savings of $5 million over three years. Over the three-year period, the Center for Health Care Services’ program will hire and train an estimated 22 health care workers, to include two health navigators, ten community guest specialists, and six certified peers support specialists. The care team will provide peer support to generate readiness for change, build motivation, and sustain compliance.
CHRISTUS ST. MICHAEL HEALTH SYSTEM
Project Title: "Reducing readmissions from nursing home facilities with the Integrated Nurse Training and Mobile Device Harm Reduction Program"
Geographic Reach: Arkansas, Texas
Funding Amount: $1,600,322
Estimated 3-Year Savings: $3,536,440
Summary: CHRISTUS St. Michael Health System, in partnership with the Community Long-Term Care Facility Partnership Group and University of the Incarnate Word, received an award to implement the Integrated Nurse Training and Mobile Device Harm Reduction Program (INTM). The INTM will train nurses to recognize early warning signs of congestive heart failure (CHF) and sepsis in Medicare beneficiaries in nursing home facilities and patients in hospitals who are vulnerable to certain preventable conditions. The project team developed an educational program that includes customized, clinical decision support mobile device training, and interactive didactic sessions. The training, in combination with computerized clinical decision support systems that guide nurses through evidence-based protocols once symptoms are detected and mobile devices loaded with clinical support system software, is anticipated to result in a 20% reduction in readmissions from long term care facilities for CHF and sepsis and fewer failure-to-rescue situations for those patients who are admitted to the hospital.
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.
MEDEXPERT INTERNATIONAL, INC
Project Title: "MedExpert International: Quality Medical Management System (QMMS)"
Geographic Reach: California, Idaho, Texas, Washington
Funding Amount: $9,332,545
Estimated 3-Year Savings: $50,410,304
Summary: MedExpert International received an award to test its Quality Medical Management System (QMMS) in comparison to a control group. QMMS is a shared decision-making system that provides consumers with access to world-expert physician advice, educational materials, and assistance with interpreting benefits and treatment options using Medical Information Coordinators and staff Physicians. QMMS will be available in selected geographic markets across the country to serve approximately 180,000 Medicare beneficiaries. The goal is to improve quality of care, reduce costs, increase transparency, achieve high utilization and satisfaction, and demonstrate model viability. Over a three-year period, MedExpert International will train and hire approximately 38 health care workers, including medical information coordinators, a medical information coordinator supervisor, a project manager, a senior executive manager, information technology and data engineers, senior engineers, and physicians.
NATIONAL COUNCIL OF YOUNG MEN'S CHRISTIAN ASSOCIATIONS OF THE UNITED STATES OF AMERICA (YMCA OF THE USA)
Project Title: "Delivery on the promise of diabetes prevention programs"
Geographic Reach: Arizona, Delaware, Florida, Indiana, Minnesota, New York, Ohio, Texas
Funding Amount: $11,885,134
Estimated 3-Year Savings: $4,273,807
Summary: The National Council of Young Men's Christian Associations of the United States of America (Y-USA), in partnership with 17 local Ys currently delivering the YMCA’s Diabetes Prevention Program, the Diabetes Prevention and Control Alliance, and 7 other leading national non-profit organizations focused on health and medicine, is serving prediabetic Medicare beneficiaries in 17 communities across 8 states in the U.S. The intervention delivers community-based diabetes prevention through a nationally-recognized diabetes prevention lifestyle change program, coordinated and taught by trained YMCA Lifestyle Coaches. The goal is to prevent the progression of prediabetes to diabetes, which will improve health and decrease costs associated with complications of diabetes, hypercholesterolemia, and hypertension. The investments made by this grant are expected to generate cost savings beyond the three year grant period. Over a three-year period, Y-USA and its partners will train an estimated 1500 workers and create an estimated eight jobs. The new jobs will include communication specialists, a program manager, a grant administrator, a workforce development manager, data specialists, training specialists, and administrative coordinator.
THE METHODIST HOSPITAL RESEARCH INSTITUTE
Project Title: “Delirium detection and prevention across the continuum”
Geographic Reach: Texas
Funding Amount: $11,785,095
Estimated 3-Year Savings: $51,744,395
Summary: Houston Methodist and Houston Methodist Research Institute, in partnership with the Baylor College of Medicine and Grand Aides Foundation, received an award to improve care for Medicare & Medicaid beneficiaries at risk for delirium and associated complications in the Houston metropolitan area. Delirium increases risk of falls, unnecessary hospitalizations, long-term cognitive impairment, and death. Through education, recognition, and prevention efforts cases of delirium could be reduced by 40 percent in the targeted population, with a corresponding reduction in hospital admissions and readmissions and improvement in care transitions. Over a three-year period, the Methodist Hospital Research Institute will hire 12 employees and subcontractors will hire an additional 15, including advanced-practice nurse practitioners, nurse educators, volunteer supervisors, and pharmacists. The project team will train more than 1,000 practitioners across five Houston Methodist hospitals, offering patients at risk for delirium targeted interventions including home health visits, nurse navigator follow up phone calls, volunteer visits for inpatients, and medication monitoring.
THE METHODIST HOSPITAL RESEARCH INSTITUTE
Project Title: “Sepsis Early Recognition and Response Initiative (SERRI)”
Geographic Reach: Texas
Funding Amount: $14,365,591
Estimated 3-Year Savings: $48,226,102
Summary: The Methodist Hospital, in partnership with the Texas Gulf Coast Sepsis Network, received an award to identify and treat sepsis before it progresses. Their program targets adult inpatients, including but not limited to Medicare and Medicaid beneficiaries in acute care hospitals, long term acute care hospitals and skilled nursing facilities in Houston, Bryan, and McAllen, Texas. Sepsis is the sixth most common reason for hospitalization and typically requires double the average length of stay. It complicates 4 out of 100 general surgery cases, has a 30 day mortality rate of 1 in 20, and leads to complications such as renal failure and cognitive decline. Through improved training, evidence-based and systematic screening for sepsis, and more timely treatment, Methodist Hospital and its partners will prevent progression of the disease, resulting in reduced organ failure rates, reduced mortality, reduced length of stay, improved patient outcomes, and lower cost. Over a three-year period, The Methodist Hospital's program will train an estimated 3,000 bedside nurses in sepsis screening and early recognition of the often subtle signs and symptoms of early sepsis. Additionally, an estimated 200 second level responders will be trained in screening, recognition and early goal directed therapy for sepsis.
THE NATIONAL HEALTH CARE FOR THE HOMELESS COUNCIL
Project Title: “Community health workers and HCH: a partnership to promote primary care”
Geographic Reach: California, Illinois, Massachusetts, Nebraska, New Hampshire, North Carolina, Ohio, Texas
Funding Amount: $2,681,877
Estimated 3-Year Savings: $1,500,000
Summary: The National Health Care for the Homeless Council is working with twelve communities across various regions in the U.S. to reduce the number of emergency department visits and lack of primary care services for over 500 homeless individuals. The intervention integrates 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. 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 and saving approximately $1.0 million.
THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT HOUSTON
Project Title: "Comprehensive care provided in an enhanced medical home to improve outcomes and reduce costs for high-risk chronically ill children”
Geographic Reach: Texas
Funding Amount: $3,701,370
Estimated 3-Year Savings: $4,272,968
Summary: The University of Texas Health Science Center at Houston received an award to improve care for children under 18 in the wider Houston area with chronic illnesses, including congenital anomalies, pulmonary problems, gastro-intestinal problems, neurologic problems, cerebral palsy, mental retardation, and a 50% or more estimated risk of hospitalization per year. The program will provide comprehensive care through a special high-risk children's medical home where both primary and specialty services are provided in the same clinic during the same visit. The clinic is staffed by a diverse team of pediatricians and pediatric nurse practitioners who are highly trained and experienced and continuously accessible to treat these complex children. Through intensive integrated and coordinated care, the program will reduce serious illnesses, emergency room visits, hospitalizations, pediatric ICU admissions, total hospital and ICU days, and total health care costs, and will improve the care, health, and quality of life for these fragile children. Over a three-year period, the University of Texas Health Science Center at Houston's program will train an estimated 35 workers. It will create an estimated six jobs, in addition to the positions for a project director, a medical director (pulmonology), an associate medical director (allergy/immunology), pediatric nurse practitioners, health care educators, a health care economist, and consultants in a pediatric infectious disease, gastroenterology, and neurology.
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 ARKANSAS FOR MEDICAL SCIENCES
Project Title: “Cost-effective delivery of enhanced home caregiver training”
Geographic Reach: Arkansas, California, Hawaii, Texas
Funding Amount: $3,615,818
Estimated 3-Year Savings: $1,286,251
Summary: The University of Arkansas for Medical Sciences received an award for enhanced training of both family caregivers and the direct-care workforce in order to improve care for elderly patients requiring long-term care services, including Medicare beneficiaries qualifying for home healthcare services and Medicaid beneficiaries who receive homemaker and personal care assistant services. Inadequate training of the direct care worker has been shown to have a direct impact on the quality of care to the elderly. By enhancing the training of the direct-care workforce, the increasingly complex care needs of the older adult can be better managed in the home, leading to fewer avoidable hospital admissions and readmissions, better preventive care, better compliance with care, and avoidance of unnecessary institutional care. The investments made by this grant are expected to generate cost savings beyond the three year grant period. Over a three-year period, The University of Arkansas for Medical Sciences’ program will train an estimated 2,100 workers and will create an estimated four jobs. The new workforce will include a project manager, a nurse educators and an administrative assistant. Additionally, this program will train home care givers in rural areas using distance education. Through tuition and textbook support in the form of microcredit loans, this program will increase the number of certified caregivers providing direct care to elderly adults.
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.