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.
CHILDREN’S HOSPITAL AND HEALTH SYSTEM, INC
Project Title: “CCHP Advanced Wrap Network”
Geographic Reach: Wisconsin
Funding Amount: $2,796,255
Estimated 3-Year Savings: $2,851,266
Summary: Children’s Hospital and Health System received an award to create Care Links, which will support members of Children’s Community Health Plan (CCHP), the system’s Medicaid HMO in Southeast Wisconsin, as they navigate the health care system. Care Links will allow community health navigators to educate and empower health plan members to navigate the health care system, connect with a primary care doctor and receive preventive care and appropriate screenings. Community health navigators will offer services to individuals and families who have had two ER visits within six months. A nurse navigator will work with health plan members diagnosed with asthma who have had one ER or one inpatient stay related to asthma. Both the community navigators and the nurse navigator will reinforce the availability of urgent care and CCHP’s 24/7 nurse advice line. The goal of Care Links is to reduce avoidable ER visits, improve health outcomes (specific HEDIS measures) and reduce cost. Over the three year period, Children’s Hospital and Health System will create nine jobs, including a program manager, community health navigators and nurse navigators.
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.
PHARMACY SOCIETY OF WISCONSIN
Project title: “Retooling the pharmacist’s role in improving health outcomes and reducing health care costs”
Geographic Reach: Wisconsin
Funding Amount: $4,165,191
Estimated 3-Year Savings: $20,448,864
Summary: The Pharmacy Society of Wisconsin received an award to better integrate community pharmacists into clinical care teams. This project, expanding the successful Wisconsin Pharmacy Quality Collaborative (WPQC), will transform the pharmacist’s role from drug dispenser to drug therapy coordinator and manager. Participating pharmacists will work collaboratively with members of the health care team to focus MTM services on patients with diabetes, heart failure, asthma, and geriatric syndromes. These patients are typically prescribed numerous medications, change locations of care, and/or are non-adherent to evidence-based therapies prescribed for them. The result of the intervention will be better medication adherence, better medication therapy management, and better health, with a decrease in adverse events and complications and more appropriate, evidence-based medication therapy. Over a three-year period, the Pharmacy Society of Wisconsin’s program will train an estimated 1,200 workers and will create an estimated 7 jobs. Regional implementation specialists will support community pharmacists across the state to successfully deliver the outcomes of the WPQC program.