Notes and Disclaimers:
- Projects shown may also be operating in other states (see the Geographic Reach)
ASSOCIATION OF AMERICAN MEDICAL COLLEGES
Project Title: "eConsults/eReferrals: Controlling Costs and Improving Quality at the Interface of Primary Care and Specialty Care"
Geographic Reach: New Hampshire, Iowa, Wisconsin, Virginia, California
Estimated Funding Amount: $7,125,770
Summary: The Association of American Medical Colleges project will test the scalability of an eConsult/eReferral model for implementation in five partner academic medical centers. The eConsults model, developed by the University of California San Francisco (UCSF), is an electronic consultation and referral (eCR) platform for access to specialty input to address several well-documented gaps in primary care-specialty care communication and coordination and provide a foundation for non-face-to-face, asynchronous electronic consultation. The proposed model has two components, both fully integrated into the Epic electronic health record. The first being implementation of a standardized set of condition-specific referral templates across 12 medical specialties, with additional surgical specialties nearing completion. These templates, developed at UCSF and refined at each academic medical center by a consensus of primary care/specialist clinicians, provide immediate decision support to the primary care provider (appropriateness of referral, recommended pre-referral tests, etc.) and ensure that all necessary information is provided to the appropriate specialist. The second component of the model is the eConsult, an asynchronous exchange initiated by the primary care provider to seek guidance from the specialist, who is expected to respond in less than 72 hours. eConsults are completed in lieu of an in-person specialist visit, though the specialist can convert an eConsult to a referral if the situation warrants and the patients will still have the option to seek care with that specialist, if desired. The eConsult system integrates into current care-delivery practices and supports the work of both the primary care provider and the specialist involved in an eConsult exchange.
NATIONAL ASSOCIATION OF CHILDREN'S HOSPITALS AND RELATED INSTITUTIONS
Project Title: "Coordinating All Resources Effectively (CARE) for Children with Medical Complexity"
Geographic Reach: California, Colorado, Florida, Missouri, Pennsylvania, Texas
Estimated Funding Amount: $23,198,916
Summary: The National Association of Children's Hospitals and Related Institutions is receiving an award to test Coordinating All Resources Effectively (CARE) for children with medical complexity (CMC), which aims to inform sustainable change in health care delivery through new payment models supporting improved care and reduced costs for CMC. The population of focus is CMC who have medical fragility and intense medical and coordination of care needs that are not well met by existing health care models. This model aims to improve care and reduce overall health care expenditures for CMC by 1) creating a medically-appropriate tiered system of care so that CMC of varying needs are cared for in the most appropriate settings to meet patient and family needs while lowering costs, 2) designing a payment system that will both sustain these programs and provide sufficient flexibility so that services will meet patient and family needs and 3) creating a learning system so that programs and payers across the country serving this population can rapidly learn from each other to improve care and design and implement effective payment models. At the center of the proposed care model are the principles of accessible, coordinated, continuous, compassionate and family centered care/shared decision making as articulated in the concept of the medical home, which has been associated with fewer hospitalizations, less emergency department use, better health, and lower costs of care.
REGENTS OF THE UNIVERSITY OF CALIFORNIA SAN DIEGO
Project Title: "San Diego: A Health Attack and Stroke Free Zone - HSF - Z"
Geographic Reach: California
Estimated Funding Amount: $5,820,416
Summary: The Regents of the University of California San Diego project will test implementation of the Health Attack and Stroke-Free Zone (HSF-Z) program, which aims to impact population health through four related, regional areas of work: (1) activate high risk patients by increasing awareness of risk factors, increasing understanding of their disease state, and increasing commitment to their physician's recommendations through the Be There campaign, (2) promote evidence based practices for heart attack and stroke prevention in the physician community through peer education and sharing best practices, (3) test novel, cost-effective technology solutions to enhance adherence to care plans, patient satisfaction, provider satisfaction, and health outcomes, and (4) implement the HSF-Z intervention for treatment of cardiovascular risk factors for 4,000 patients. The HSF-Z model is based on the premise that significant reduction of blood pressure and cholesterol levels is possible using evidence based practices and achieving patient adherence. The model targets both patients and primary care clinical teams and will also explore the use of emerging wireless and other technologies to monitor patient progress and compliance.
REGENTS OF THE UNIVERSITY OF CALIFORNIA SAN FRANCISCO
Project Title: "The UCSF and UNMC Dementia Care Ecosystem: Using Innovative Technologies to Personalize and Deliver Coordinated Dementia Care"
Geographic Reach: California, Nebraska
Estimated Funding Amount: $9,990,848
Summary: The Regents of the University of California San Francisco project will implement Care Ecosystem, an innovative clinical program that builds on the UCSF Memory and Aging Center's 15-year history of offering high-quality dementia care, while incorporating the University of Nebraska Medical Center's specialized expertise in functional monitoring and rural dementia care. Whereas most dementia care today is crisis-oriented and reactive, this model emphasizes continuous and personalized care. The target population is Medicare beneficiaries and persons dually eligible for Medicare and Medicaid. By supporting family caregivers, keeping patients healthy, and helping them prepare together for advancing illness, this model aims to improve satisfaction with care, prevent emergency-related health care costs, and keep patients in the home longer. The primary point of contact for patients and families will be a Care Team Navigator (CTN) with 24/7 availability. An innovative "dashboard" with both CTN and patient portals will drive efficient and personalized communication between the CTN, care team, and the patient and family. The 4 modules of Care Ecosystem are as follows. The Caregiver Module will include educational forums and connect families with community resources. The Decision-Making Module will facilitate proactive medical, financial, and safety decisions. The Medication Module will track and reduce inappropriate medications or doses and trigger a pharmacist review when indicated. The Functional Monitoring module will use smartphones and sensors to rapidly detect and respond to changes in functional status, which is particularly important for patients living remotely, alone, or who are at-risk for acute declines.
VENTURA COUNTY HEALTH CARE AGENCY
Project Title: "COPD Access to Community Health (CATCH)"
Geographic Reach: California
Estimated Funding Amount: $4,136,499
Summary: The Ventura County Health Care Agency project will test implementation of Chronic Obstructive Pulmonary Disease (COPD) Access to Community Health (CATCH), a community-based care coordination program based on the chronic care model. Care coordination activities include: (1) clinical, psychosocial, and environmental assessments; (2) care plan development with the primary care providers (PCPs); and (3) specialist input. The development of the care plan is based on 2013 Global Initiative for Chronic Obstructive Lung Disease guidelines that include: patient education and self-management training; care management; community referral and coordination; home visitation; monitoring and feedback; and follow-up and reassessment. Community outreach will include community education, risk assessment, screening, and referral to PCPs/medical homes. Health internet technology integration and clinical provider/PCP training will be implemented to promote evidence-based practices. The model aims to improve stability of the COPD condition and reduce emergency room visits, inpatient days, and overuse of PCPs. Integration of clinical care guidelines in clinical practice will significantly reduce costs by ensuring patients access the appropriate level of care (nurse, PCP, pulmonologist or other specialist) for their condition.