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.
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.
Project Title: "MyHealth Team: regional team-based and closed-loop control innovation model for ambulatory chronic care delivery"
Geographic Reach: Kentucky, Tennessee
Funding Amount: $18,846,090
Estimated 3-Year Savings: $27,269,705
Summary: Vanderbilt University received an award to improve chronic disease management, care coordination, and transition management for high-risk, high cost patients with conditions such as hypertension, congestive heart failure, and diabetes. Many of these patients are beneficiaries of Medicare and Medicaid, living in 18 rural and urban counties in Tennessee and Kentucky. To improve disease management, Vanderbilt will create inter-professional health care teams and enhanced health information technology (HIT), including disease registries and evidence-based decision support integrated into the clinical workflow. Because an inter-professional staff with access to HIT will improve communication, care planning and monitoring, the health care teams will be better able to respond to patients between office visits, track and follow up acute care episodes, and provide advanced alerts and decision-making support, resulting in improved coordination of care and reduced hospital admissions, readmissions, and emergency room visits. Over a three-year period, the Vanderbilt University program will train an estimated 45 workers and will create an estimated 45 jobs. The new workforce will include registered nurses and medical assistants.
VANDERBILT UNIVERSITY MEDICAL CENTER
Project Title: “Reducing hospitalizations in Medicare beneficiaries; a collaboration between acute and post-acute care”
Geographic Reach: Kentucky, Tennessee
Funding Amount: $2,449,241
Estimated 3-Year Savings: $8,700,000
Summary: Vanderbilt University Medical Center, in partnership with National HealthCare Corporation and two other Post-Acute Care facilities, received an award for a program designed to reduce inpatient re-hospitalization by 17% and improve patient experience for approximately 27,000 Medicare and beneficiaries dually eligible for Medicare and Medicaid in ten counties in Tennessee, including rural and underserved areas. Their project will offer improved hospital discharge planning, evidence-based interventions, and improved clinical responsiveness at post-acute facilities with estimated savings of approximately $8.7 million. Over the three-year period, Vanderbilt University Medical Center’s program will train an estimated 30 health care workers and create an estimated 4.6 new jobs. These workers will coordinate discharge planning and care transitions for patients and help integrate clinical responsiveness into post-acute care settings.