Notes and Disclaimers:
- Projects shown may also be operating in other states (see the Geographic Reach)
Project Title: "Avera Virtual Care Center: Improving Care & Reducing Costs for the Vulnerable Elderly Population"
Geographic Reach: Iowa, Minnesota, Nebraska, South Dakota
Estimated Funding Amount: $8,827,573
Summary: The Avera Virtual Care Center project will test the virtual wrapping of a set of comprehensive, resident-centered, geriatric care services around the long term care population. The project will operate in facilities located in South Dakota, Minnesota, Iowa and Nebraska. The three primary drivers of this project include: building the assessment capability and toolkits of the long term care team of care providers; providing long term care facility residents with routine and early access to appropriate goal-directed care; and improving management of care transitions. A Virtual Care Team will host INTERACT II training sessions and skill building workshops for long term care staff and will facilitate widespread implementation of INTERACT II tools and treatment algorithms to support earlier identification of urgent issues. The INTERACT II implementation will be further supported by high-quality care planning resources and training to promote alignment of resident care goals and treatment plans. To address the geriatric care access gap, the Virtual Care Team will offer daily rounds, comprehensive geriatric assessments and urgent care visits to address resident health needs in a timely manner. These services will be provided out of a centrally staffed telemedicine hub, spreading the expertise of one team over 30 long term care centers. To maximize safety and continuity across transitional points in care, the Virtual Care Center team will promote the adoption of standardized tools and processes.
CATHOLIC HEALTH INITIATIVES IOWA CORP., DBA MERCY MEDICAL CENTER DES MOINES
Project Title: "Transitioning a Rural Health Network to Value-Based Care"
Geographic Reach: Iowa, Nebraska
Estimated Funding Amount: $10,171,220
Summary: Catholic Health Initiatives Iowa Corporation is receiving an award to test a model to transition a network of rural critical access hospitals to value-based care through improved chronic disease management, increased clinical-community integration and 'lean' process improvement initiatives. Once the value-based care infrastructure has been established, the 25 critical access hospitals, including their 73 primary care clinics, will be enrolled in Mercy's Accountable Care Organization (ACO) and benefit from shared savings, resulting in model sustainability. The model is based on the approach of the Mercy ACO, which has used a similar model in its urban clinics and has achieved successful outcomes. This model includes public and private payers, rural leadership, expertise in barriers to quality care in rural communities, and utilizes Mercy's evidence-based chronic care health coach and disease registry that aim to improve care and reduce costs.
THE NEBRASKA MEDICAL CENTER
Project Title: "Remote Interventions Improving Specialty Complex Care (RIISCC)"
Geographic Reach: Nebraska
Estimated Funding Amount: $9,993,626
Summary: The Nebraska Medical Center is receiving an award to test the Remote Interventions Improving Specialty Complex Care(RIISCC) model, which aims to employ remote patient monitoring for 90 days post-discharge by utilizing telehealth consultations for participants at one of two community health centers located within the target geographic areas. Participants will receive telehealth equipment as well as an orientation to the program which includes 90 day remote monitoring, weekly calls from remote monitoring coaches to discuss critical values and provide education and coaching, a retinal eye imaging scan and follow up consults with an ophthalmologist if needed, a nutritional consult with a registered dietician, and gift card incentives to encourage participation and retention. The target population resides in medically underserved areas and often experience barriers in access to health care.
REGENTS OF THE UNIVERSITY OF CALIFORNIA SAN FRANCISCO
Project Title: "The UCSF and UNMC Dementia Care Ecosystem: Using Innovative Technologies to Personalize and Deliver Coordinated Dementia Care"
Geographic Reach: California, Nebraska
Estimated Funding Amount: $9,990,848
Summary: The Regents of the University of California San Francisco project will implement Care Ecosystem, an innovative clinical program that builds on the UCSF Memory and Aging Center's 15-year history of offering high-quality dementia care, while incorporating the University of Nebraska Medical Center’s specialized expertise in functional monitoring and rural dementia care. Whereas most dementia care today is crisis-oriented and reactive, this model emphasizes continuous and personalized care. The target population is Medicare beneficiaries and persons dually eligible for Medicare and Medicaid. By supporting family caregivers, keeping patients healthy, and helping them prepare together for advancing illness, this model aims to improve satisfaction with care, prevent emergency-related health care costs, and keep patients in the home longer. The primary point of contact for patients and families will be a Care Team Navigator (CTN) with 24/7 availability. An innovative "dashboard" with both CTN and patient portals will drive efficient and personalized communication between the CTN, care team, and the patient and family. The 4 modules of Care Ecosystem are as follows. The Caregiver Module will include educational forums and connect families with community resources. The Decision-Making Module will facilitate proactive medical, financial, and safety decisions. The Medication Module will track and reduce inappropriate medications or doses and trigger a pharmacist review when indicated. The Functional Monitoring module will use smartphones and sensors to rapidly detect and respond to changes in functional status, which is particularly important for patients living remotely, alone, or who are at-risk for acute declines.