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.
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.
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, Indiana, Kansas, Kentucky, Maryland, Massachusetts, Michigan, Mississippi, Nebraska, North Carolina, Oklahoma, South Dakota, West Virginia
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.
UNIVERSITY OF ALABAMA AT BIRMINGHAM
Project Title: "Deep South Cancer Navigation Network (DSCNN)"
Geographic Reach: Alabama, Florida, Georgia, Mississippi, Tennessee
Funding Amount: $15,007,263
Estimated 3-Year Savings: $49,815,239
The University of Alabama at Birmingham (UAB) and the UAB Comprehensive Cancer Center received an award extending a regional network of lay health workers to expand comprehensive cancer care support services through a five state region. Working through the participating UAB Health System Cancer Community Network associate sites, the program seeks to create a national model for improving the quality of cancer care while decreasing unnecessary hospital utilization and enhancing patient satisfaction.
The program, named “Patient Care Connect,” is designed to serve Medicare beneficiaries with complex or advanced stage cancers, including those with psycho-social barriers to appropriate care, many living in medically underserved inner city and rural communities. Each navigation team will include an RN site manager and specially trained non-clinical patient navigators. The navigation teams will focus on helping patients by providing information about their cancer treatment, empowering patients to make informed choices about their care, providing emotional support and problem-solving, assisting with overcoming common barriers to cancer treatment, and helping patients make wise use of healthcare resources.
It is expected that the program will result in a reduction in emergency room visits and unnecessary hospital utilization, earlier acceptance of palliative and hospice services, better adherence to evidence based care plans, and an improved overall quality of life for cancer patients.