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.
BETH ISRAEL DEACONESS
Project Title: “Preventing avoidable re-hospitalizations: Post-Acute Care Transition Program (PACT)”
Geographic Reach: Massachusetts
Funding Amount: $4,937,191
Estimated 3-Year Savings: $12,900,000
Summary: Beth Israel Deaconess Medical Center (BIDMC) of Boston, Massachusetts, received an award to improve care transitions and reduce hospital readmissions for Medicare beneficiaries and beneficiaries dually eligible for Medicare and Medicaid. By integrating care, improving patients’ transitions between locations of care, and focusing on a battery of evidence-based best practices, this model is expected to prevent complications and reduce preventable readmissions, resulting in better quality health care at lower cost in the urban Boston area with estimated savings of almost $13 million over 3 years.
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.
HEALTH RESOURCES IN ACTION
Project Title: “New England asthma innovations collaborative”
Geographic Reach: Connecticut, Massachusetts, Rhode Island, Vermont
Funding Amount: $4,040,657
Estimated 3-Year Savings: $4,100,000
The "New England Asthma Innovation Collaborative” (NEAIC) is a multi-state, multi-sector partnership convened by the Asthma Regional Council of New England (ARC), a program of Health Resources in Action (HRiA), that includes health care providers, payers, and policy makers aimed at creating an innovative Asthma Marketplace in New England that will increase the supply and demand for high-quality, cost-effective health care services delivered to Medicaid children with severe asthma. Our goal is to create a sustainable infrastructure that robustly delivers evidence-based cost-effective asthma care to New England children with severe disease, and creates viable Medicaid reimbursement mechanisms to support these programs over the long-term. The targeted population is high-cost Medicaid and CHIP pediatric patients (2 – 17 years), with a focus on those with uncontrolled symptoms that have a history of using expensive urgent care. NEAIC includes following components:
1. Workforce development: NEAIC will: a) sponsor Asthma Training to increase the number of well qualified cost-effective providers, including certified asthma educators (AE-Cs) and community health works (CHWs) with a specialty in asthma; and b) explore CHW asthma credentialing program that payers and provider practices across NE have requested and can benefit from. All of this will contribute to higher quality and culturally competent care, and we believe will help to support innovative Medicaid reimbursement as a result of demonstrated cost-effective outcomes.
2. Rapid service delivery expansion for over 1300 high-risk children with asthma in Connecticut, Rhode Island, Massachusetts, and Vermont. NEAIC employs the following components of care: 1) Asthma self-management education 2) Home environmental assessment with the provision of minor-to-moderate environmental intervention supplies to reduce asthma triggers; and 3) Use of non-physician providers shown to be cost-effective deliverers of this level of care, particularly community health workers (CHWs) and certified asthma educators (AE-Cs).
3. Committed Medicaid payers in several New England states will work to sustain these programs by piloting reimbursement methodologies with the service providers, should the service model results demonstrate the goals of delivering better health, improving care and lowering costs..
4. A Payer and Provider Learning Community across all six New England states to rapidly disseminate demonstrated improvements to the quality and cost of asthma care, share viable reimbursement systems developed, successfully incorporate CHWs into the asthma care team, and disseminate best practices. The Learning Community builds on ARC’s existing networks and partnerships across the region, and is meant to increase awareness about these successful models with the goal of broader adoption across New England.
NEAIC’s components build in continuous quality improvement measures through rigorous data collection/analysis, strong partnerships, and commitments from interested payers and policy makers. The establishment and promotion of CHWs as strong health care delivery partners addressing environmental conditions as part and parcel of the disease management program, with reimbursement by payers, make this an innovative model for broad dissemination and potential for replication across the nation.
INSTITUTE FOR CLINICAL SYSTEMS IMPROVEMENT
Project Title: “Care management of mental and physical co-morbidities: a TripleAim bulls-eye"
Geographic Reach: California, Colorado, Massachusetts, Michigan, Minnesota, Pennsylvania, Washington, Wisconsin
Funding Amount: $17,999,635
Estimated 3-Year Savings: $27,693,046
Summary: The Institute for Clinical Systems Improvement (ICSI) of Bloomington, Minnesota received an award to improve care delivery and outcomes for high-risk adult patients with Medicare or Medicaid coverage who have depression plus diabetes or cardiovascular disease. The program will use care managers and health care teams to assess condition severity, monitor care through a computerized registry, provide relapse and exacerbation prevention, intensify or change treatment as warranted, and transition beneficiaries to self-management. The partnering care systems include clinics in ICSI, Mayo Clinic Health System, Kaiser Permanente in Colorado and Southern California, Community Health Plan of Washington, Pittsburgh Regional Health Initiative, Michigan Center for Clinical Systems Improvement, and Mount Auburn Cambridge Independent Practice Association with support from HealthPartners Research Foundation and AIMS (Advancing Integrated Mental Health Solutions). Over a three-year period, ICSI and its partners will train the approximately 80+ care managers needed for this new model.
Project Title: “Patient-centric electronic environment for improving acute care performance”
Geographic Reach: Massachusetts, Minnesota, New York, Oklahoma
Funding Amount: $16,035,264
Estimated 3-Year Savings: $81,345,987
Summary: The Mayo Clinic received an award to improve critical care performance for Medicare and Medicaid beneficiaries in intensive care units (ICUs). The goal of this project is to develop and test a novel acute care interface with built-in-tools for error prevention, practice surveillance, decision support and reporting (ProCCESs AWARE - Patient Centered Cloud-based Electronic System: Ambient Warning and Response Evaluation). In preliminary studies, these novel informatics support builds on advanced understanding of cognitive and organizational ergonomics, have significantly decreased cognitive load of bedside providers and reduced medical errors. Using a cloud-based technology, AWARE will be uniformly available on either mobile or fixed computing devices and applied in a standardized manner in medical and surgical ICUs of geographically diverse acute care hospitals predominantly serving Medicare and Medicaid patients. The impact of ProCCESs AWARE on processes of care and outcomes in study ICUs will be evaluated using standardized step-wedge cluster randomized study design expected to enroll more than 10,000 critically ill patients during the three year study period. Over a three-year period, the Mayo Clinic will train 1440 existing ICU caregivers in four diverse hospital systems to use new health information technologies effectively in managing ICU patient care.
Project Title: “Integrating industrial and system engineering (ISE) methods into healthcare improvement"
Geographic Reach: Massachusetts, North Carolina, Washington
Funding Amount: $8,000,002
Estimated 3-Year Savings: $60,780,907
Summary: The Healthcare Systems Engineering Institute at Northeastern University received an award to conduct a National Demonstration Project of the value that the systems engineering methods used in other complex industries can also be used to reduce healthcare costs, improve quality and safety, reduce waits and delays, and improve clinical outcomes and overall population health. Under this award, Northeastern will create a model regional healthcare systems engineering extension center that partners with several local healthcare systems, applies systems engineering methods to targeted common problems to significantly impact the goals of better outcomes, better health, and at lower costs, and develops an implementation plan for national spread. This award funds the first phase of a larger scale 10-year project to establish a national network of similar healthcare systems engineering regional extension centers across the U.S. that develop and embed regional industrial and systems engineering improvement science academic departments and other resources into their local healthcare systems, saving billions annually while training a targeted future workforce of 15,000 healthcare systems engineers.
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.
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.
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.
Project Title: "Using recovery peer navigators and incentives to improve substance abuse Medicaid client outcomes and costs”
Geographic Reach: Massachusetts
Funding Amount: $2,760,737
Estimated 3-Year Savings: $7,841,498
ValueOptions, Inc., with its subsidiary, Massachusetts Behavioral Health Partnership, received an award to test care coordination to reduce repeated utilization of detox services among beneficiaries who have 2 or more detox admissions. With Brandeis University as a research partner, the project uses patient navigators, recovery planning,and behavioral interventions to support member recovery. Four providers will implement the interventions, serving northeastern Massachusetts, southeastern Massachusetts, greater Boston, and the central portion of the state. By linking beneficiaries with appropriate treatment and recovery services, the model will improve their health outcomes, reducing costs by avoiding preventable emergency room visits, hospitalizations and detox readmissions.
Over a three-year period, ValueOptions, Inc.’s program will train an estimated 75 workers and will create an estimated 75 jobs. The new workers will include patient navigators and support staff.
Project Title: "Community-based health homes for individuals with serious mental illness”
Geographic Reach: Massachusetts
Funding Amount: $2,942,962
Estimated 3-Year Savings: $3,792,020
Summary: Vinfen Corporation, in partnership with Bay Cove Human Services, North Suffolk Mental Health Association, Brookline Mental Health Center, Commonwealth Care Alliance, Robert Bosch Healthcare, and Dartmouth University received an award to integrate primary and behavioral health care for individuals with serious mental illness in the metropolitan Boston area. The project embeds Nurse Practitioners, backed by a primary care physician, into existing community based psychiatric rehabilitation and recovery teams, creating community based health homes that provide better care at lower cost for a population at risk for severe chronic disease. Embedded Health Outreach Workers teach participants to manage their behavioral and physical health effectively and more independently. This care team uses telehealth technology to monitor participants’ signs and symptoms, prioritize care and deliver necessary interventions. As a result, the project aims to improve the health of participants, increase their access to primary and specialty health care and reduce the use of costly acute care services.