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
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.