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.
CHRISTIANA CARE HEALTH SYSTEM
Project Title: “Bridging the Divides”
Geographic Reach: Delaware, Maryland, New Jersey, Pennsylvania
Funding Amount: $9,999,999
Estimated 3-Year Savings: $376,327
Summary: Christiana Care Health System, serving the state of Delaware, received an award to create and test a system that uses a ”care management hub” and combines information technology and carefully coordinated care management to improve care for post-myocardial infarction and revascularization patients, the majority of them Medicare or Medicaid beneficiaries. Christiana Care will integrate statewide health information exchange data with cardiac care registries from the American College of Cardiology and the Society of Thoracic Surgeons, enabling more effective care/case management through near real time visibility of patient care events, lab results, and testing. This will decrease emergency room visits and avoidable readmissions to hospitals and improve interventions and care transitions. The investments made by this grant are expected to generate cost savings beyond the three year grant period. Over a three-year period, Christiana Care Health System will create an estimated 16 health care jobs, including positions for nurse care managers, pharmacists, and social workers.
COOPER UNIVERSITY HOSPITAL
Project Title: N/A
Geographic Reach: New Jersey
Funding Amount: $2,788,457
Estimated 3-Year Savings: $6,200,000
Summary: Cooper University Hospital in conjunction with the Camden Coalition of Healthcare Providers, serving Camden, New Jersey, received an award to better serve approximately 600 Camden residents with complex medical needs who have relied on emergency rooms and hospital admissions for care. The intervention will use nurse led interdisciplinary outreach teams to work with enrolled participants to reduce hospital readmissions and improve their access to primary health care. This approach is expected to result in better health care outcomes and lower cost with estimated savings of over $6 million. Over the three-year period, Cooper University Hospital’s program will train an estimated 22 health care workers, while creating an estimated 16 new jobs. These workers will include non-clinical staff, like AmeriCorps volunteers and community health workers, who will serve as part of the multidisciplinary teams to support care coordination activities.
DEVELOPMENTAL DISABILITIES HEALTH SERVICES
Project Title: “Expanding and testing a Nurse Practitioner-led health home model for individuals with developmental disabilities”
Geographic Reach: Arkansas, New Jersey, New York
Funding Amount: $3,701,528
Estimated 3-Year Savings: $5,374,080
Summary: Developmental Disabilities Health Services received an award to test a developmental disabilities health home model using care management/primary care teams of nurse practitioners and MDs to improve the health and care of persons with developmental disabilities in important clinical areas. This health home model serves individuals with intellectual and developmental disabilities who receive Medicaid and/or Medicare benefits in New Jersey, the Bronx, and Little Rock, Arkansas, and are eligible for services in each state's Home- and Community-Based Services waiver program, as well as individuals who are commercially insured and uninsured. All of the patients are considered high-risk and many have co-morbidities. By integrating care using nurse practitioners as care coordinators and health care providers, the health homes are improving primary care, mental health care, basic neurological care, and seizure management for these beneficiaries, resulting in reduced emergency room visits and lower out-of-home placement and institutionalization. Over a three-year period, Developmental Disabilities Health Services will retrain and deploy 20 individuals to provide and coordinate primary care and mental health services in health homes for persons with developmental disabilities.
MOUNT SINAI SCHOOL OF MEDICINE
Project Title: "Geriatric emergency department innovations in care through workforce, informatics, and structural enhancements (GEDI WISE)"
Geographic Reach: Illinois, New Jersey, New York
Funding Amount: $12,728,753
Estimated 3-Year Savings: $40,124,805
Summary: The Icahn School of Medicine at Mount Sinai received an award to implement a new model of geriatric emergency care in three large, urban hospitals: The Mount Sinai Medical Center in New York City, St. Joseph’s Regional Medical Center in Paterson, NJ, and Northwestern Memorial Hospital in Chicago, IL. Geriatric Emergency Department Innovations in care through Workforce, Informatics and Structural Enhancements (GEDI WISE) is a multidisciplinary collaboration that has embraced a new care paradigm, the geriatric emergency department, which has transformed both the physical environment and processes of care in these three emergency departments (ED). GEDI WISE uses evidence-based geriatric clinical protocols, informatics support for patient monitoring and clinical decision-making, and structural enhancements to improve patient safety and satisfaction while decreasing hospitalizations, return ED visits, unnecessary diagnostic and therapeutic services, medication errors, and adverse events, such as falls and avoidable complications. Over a three-year period, GEDI WISE will train more than 400 current health care workers and create 22 new jobs including nurses, nurse practitioners, pharmacists, physical therapists, project coordinators, data analysts and geriatric transitional care managers.
THE TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Project Title: “A rapid cycle approach to improving medication adherence through incentives and remote monitoring for coronary artery disease patients”
Geographic Reach: Delaware, New Jersey, New York, Pennsylvania
Funding Amount: $4,841,221
Estimated 3-Year Savings: $2,787,030
Summary: The University of Pennsylvania received an award for a program to improve medication adherence and health outcomes in patients who have recently been discharged from the hospital with acute myocardial infarction. Such patients typically have high rates of poor medication adherence and hospital readmissions and are costly to monitor through intensive case management. The intervention will increase medication adherence through remote monitoring, medication reminders, incentives, and support from family and friends. It will also retrain social workers as engagement advisors to provide additional support as needed. The result will be improved health outcomes and lower cost. The investments made by this grant are expected to generate cost savings beyond the three year grant period. Over a three-year period, University of Pennsylvania’s program will train an estimated 21 workers, while creating an estimated seven jobs for investigators, clinical social workers, a software developer, project coordinators, and a project director.
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.