Health Care Innovation Awards: Project Profile

RUTGERS, THE STATE UNIVERSITY OF NEW JERSEY (THE CENTER FOR STATE HEALTH POLICY)

Project Title: “Sustainable high-utilization team model”
Geographic Reach: California, Colorado, Missouri, Pennsylvania
Funding Amount: $14,347,808
Estimated 3-Year Savings: $67,719,052

Summary

Rutgers, The State University of New Jersey, received an award to expand and test a team-based care management strategy for high-cost, high-need, low-income populations served by safety-net provider organizations in Allentown, PA, Aurora, CO, Kansas City, MO, and San Diego, CA. Led by Rutgers Center for State Health Policy, the project will use integrated care management teams (including nurses, social workers, and community health workers) to provide clients with patient-centered support that addresses both health care needs and the underlying determinants of health. Teams will assist patients in managing chronic illness, including filling prescriptions and coordinating appropriate specialty care, in addition to addressing social service needs such as identifying stable housing, applying for health coverage or disability benefits and facilitating transportation arrangements. After patients are stabilized, the care management team will transition them to local primary care medical homes. By improving beneficiaries’ access to ambulatory medical and social services, the project will improve patient outcomes and reduce preventable hospital inpatient and emergency room utilization. Over a three-year period, Rutgers’s program will create an estimated 43 jobs across multiple health care professions.

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