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.
LE BONHEUR COMMUNITY HEALTH AND WELL BEING
Project Title: "Le Bonheur's CHAMP Program: Changing High-risk Asthma in Memphis through Partnership"
Geographic Reach: Memphis and Shelby County, Tennessee
Funding Amount: $2,896,416
Estimated 3-Year Savings: $4,003,397
Summary: Le Bonheur Children’s Hospital, Division of Community Health and Well Being and the University of Tennessee Health Science Center are collaborating to serve children with high-risk asthma in Memphis/Shelby County, Tennessee. CHAMP features an asthma registry, a repository of critical information on all CHAMP patients that will be accessed by a variety of providers caring for the patients. Additionally, the registry is a means to document all CHAMP activities, track all elements of the CHAMP monitoring plan, and produce reports for use in the PDSA process. Patients receive medical care and assessment by CHAMP physician sub-specialists. The Community Coordination team, comprised of two Asthma Care Coordinators and 4 Community Health Workers who are supervised by a Licensed Clinical Social Worker, provides asthma education; environmental assessment; coordination with schools and child care; and provides help with barriers to asthma management. The final component is the collaboration with the primary care physicians, school health, and other community partners. The self-monitoring aspects of CHAMP are managed by a program evaluator and a data analyst. CHAMP aims to reduce emergency room visits, avoidable hospitalizations, school absence due to asthma, and child deaths due to asthma. Additionally CHAMP seeks to improve school attendance, improve quality of life, and improve the experience of health care, all at a lower cost of care.
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.
UNIVERSITY OF TENNESSEE HEALTH SCIENCE CENTER
Project Title: "Project SAFEMED"
Geographic Reach: Arkansas, Mississippi, Tennessee
Funding Amount: $2,977,865
Estimated 3-Year Savings: $3,160,844
Summary: The University of Tennessee Health Science Center, in partnership with Methodist LeBonheur Healthcare's Methodist North Hospital and Methodist South Hospital and community partners received an award to improve care transitions with an emphasis on medication management among high repeat utilizing patients in the northwest and southwest sections of Memphis, TN. The program will serve vulnerable adults (20-64) and seniors 65+ insured by Medicaid and/or Medicare who have multiple chronic diseases, including hypertension, diabetes, coronary artery disease, congestive heart failure, and chronic lung disease with presence of polypharmacy or high risk medications. Through multidisciplinary teams encompassing pharmacy, nursing, and social work based in outpatient centers, the program will enhance discharge planning, improve post-discharge outreach and follow-up, increase access to community based services and coordinate care across providers and settings. In addition, pharmacy technicians and licensed practical nurses will serve as outreach workers engaging patients through home visits, intense phone follow up, and group based support sessions. This approach will improve medication adherence to safe and effective medication regimens, overall chronic disease self-management, health services utilization patterns, and patient experience of care. Over a three-year period, the University of Tennessee Health Science Center's program will develop 5 new roles for direct care staff and create 11 jobs in the healthcare field.
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.