Health Care Innovation Awards Round Two: New York

Notes and Disclaimers:

• Projects shown may also be operating in other states (see the Geographic Reach)

ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI

Project Title: "Bundled Payment for Mobile Acute Care Team Services"
Geographic Reach: New York
Estimated Funding Amount: $9,619,517

Summary: The Icahn School of Medicine at Mount Sinai project will test Mobile Acute Care Team (MACT) Services, which will utilize the expertise of multiple providers and services already in existence in most parts of the United States but will transform their roles to address acute care needs in an outpatient setting. MACT is based on the hospital-at-home model, which has proven successful in a variety of settings. MACT will treat patients requiring hospital admission for selected conditions at home. The core MACT team will involve physicians, nurse practitioners, registered nurses, social work, community paramedics, care coaches, physical therapy, occupational therapy and speech therapy, and home health aides. The core MACT team will provide essential ancillary services such as community-based radiology, lab services (including point of care testing), nursing services, durable medical equipment, pharmacy and infusion services, telemedicine, and interdisciplinary post-acute care services for 30 days after admission. After 30 days, the team will ensure a safe transition back to community providers and provide referrals to appropriate services.

FUND FOR PUBLIC HEALTH IN NEW YORK, INC.

Project Title: "Project INSPIRE NYC (Innovate & Network to Stop HCV & Prevent complications via Integrating care, Responding to needs and Engaging patients & providers"
Geographic Reach: New York
Estimated Funding Amount: $9,948,459

Summary: The Fund for Public Health in New York and the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) are testing a model that will identify persons with Hepatitis C viral (HCV) infection utilizing the NYC DOHMH HCV surveillance database, electronic medical and laboratory records from participating facilities, and referrals from neighborhood organizations that perform HCV testing. Eligible persons will undergo an interdisciplinary, comprehensive medical and behavioral health assessment, for substance use and social support and benefits needs. Patients' behavioral health will be assessed using the Psychosocial Readiness Evaluation and Preparation for Hepatitis C Treatment (PREP-C), to identify areas of psychosocial functioning that require attention before and after beginning HCV treatment. HCV and related co-morbidities will be managed within an integrated, patient-centered clinical and behavioral health environment. Primary care and/or HIV providers will be supported by addiction medicine specialists, psychiatrists and hepatologists, who will be available for telemedicine-based consultation. Providers will be trained and mentored in HCV care and treatment by the institutions' hepatologists. Web-based teaching modules and weekly case management video conferences with hepatologists and providers from all participating clinics will be used. Patient management will be supported and facilitated by care coordination, defined as health system navigation and patient support to keep medical appointments, health promotion, medication adherence assistance, and coaching for improvement of self-sufficiency skills. Comprehensive care coordination programs and integrated care have been shown to improve health outcomes and reduce hospitalization and emergency department visits.

MONTEFIORE MEDICAL CENTER

Project Title: "Bronx Behavioral Health Integration Project (BHIP): Across the Lifespan in Urban Safety Net Primary Care Settings"
Geographic Reach: New York
Estimated Funding Amount: $5,583,091

Summary: The Montefiore Medical Center project will test implementation of the Bronx Behavioral Health Integration Project (B-HIP), which aims to improve the health of Bronx residents through two interrelated mechanisms, first by engaging patients with serious behavioral health needs and secondly by screening for, identifying and addressing behavioral health co-morbidities in a Collaborative Care Management (CCM) model. The target population includes Medicare, Medicaid beneficiaries and persons eligible for both programs. As part of routine primary care, patients of all ages will be screened for behavioral health conditions using validated instruments. Those with behavioral health needs will be managed by an CCM team of a primary care physician, psychiatrist, social worker or psychologist and care manager that supports the primary care team by providing screening, assessments, treatment and follow-up care with measurement-based tracking, stepped care algorithms and self-management and behavioral action techniques.

NEW YORK CITY HEALTH AND HOSPITALS CORPORATION

Project Title: "ED Care Management Initiative: Preventing Avoidable ED/Inpatient Use"
Geographic Reach: New York
Estimated Funding Amount: $17,916,663

Summary: The New York City Health and Hospitals Corporation project will test an Emergency Department Care Management model, which expands and enhances a current successful pilot program. This model utilizes a multi-disciplinary team that will comprehensively assess patients who present in the emergency department for an ambulatory-care sensitive condition (ACSC), create a care plan that would avoid an unnecessary hospitalization, and provide ongoing support after discharge, including medication management, education, and linkages with primary care providers. The program will operate in 6 hospitals.

NORTH SHORE LIJ HEALTH SYSTEM, INC.

Project Title: "Healthy Transitions in Late Stage Kidney Disease"
Geographic Reach: New York
Estimated Funding Amount: $2,453,742

Summary: The North Shore-LIJ Health System, Inc. project will implement the Healthy Transitions (HT) Program, which aims to improve late stage chronic kidney disease costs and outcomes. The model is based on a successful pilot and aims to integrate and coordinate aspects of chronic kidney disease care. The primary interventions center on improving patient education and preparation for renal replacement treatment, increasing home dialysis and preemptive transplantation, home safety, dietary counseling, depression screening, advanced directive counseling, detecting medication errors, identifying hospitalization risk and intervening to reduce risk. Nurse care managers will work in close collaboration with treating nephrologists. The HT chronic kidney disease informatics system creates a daily report with alerts that drives key care processes.

THE TRUSTEES OF COLUMBIA UNIVERSITY IN THE CITY OF NEW YORK

Project Title: ""MySmileBuddy": Demonstrating the Value of Technology-assisted Non-surgical Care Management in Young Children"
Geographic Reach: New York
Estimated Funding Amount: $3,870,446

Summary: The Trustees of the Columbia University in the City of New York project will test a model that uses family-level, peer-counseled, and technology-assisted behavioral risk reduction strategies, aims to divert children with early- and advanced-stage early childhood caries (ECC) from high-cost surgical dental rehabilitation (DR) to low-cost non-surgical disease management (NSDM). Together, parents and community health workers (CHWs) will use MySmileBuddy (MSB), a mobile tablet-based health technology, to plan, implement, and monitor positive oral health behaviors, including dietary control and use of fluorides, which arrest ECC's progression. MSB was designed with a strong theoretical basis, which applies key principles of risk-based triage, early intervention, individualization, and motivational interviewing. MSB is designed to enhance parental knowledge, skills, and self-efficacy to reduce caries-related risk factors, proportionate to their child's ECC experience. CHWs will meet in person with parents of children with early-stage ECC bimonthly for 1 year, and with parents of children with advanced-stage ECC weekly for the first 4 weeks, then bimonthly thereafter for the remainder of the year. Additionally, CHWs will provide tailored telephone intervention between in-person meetings to provide additional support and reinforce behavior change goals. CHWs will also assist parents in scheduling semiannual dental examinations at affiliated sites.

VILLAGE CENTER FOR CARE

Project Title: "VillageCare's Treatment Adherence through the Advanced Use of Technology (TAAUT)"
Geographic Reach: New York
Estimated Funding Amount: $8,781,296

Summary: The Village Center for Care project will implement "Treatment Adherence through the Advanced Use of Technology (TAAUT)." This project aims to increase patient activation for people living with HIV/AIDS by increasing access to professional and peer support for health behavior change and compliance. The program expects to improve adherence by providing timely, tailored interventions through virtual visits, social media, text messaging. Professional Care Adherence Managers will work with patients to create goals and recommend interventions from the advanced technology available. In addition, peers will be leveraged to provide one-on-one encouragement and advice, while the private social network will serve as a platform for both clinician and patient access. Customized, timely healthcare information and messages will be sent to patients through the portal and in turn, clients can provide timely information to their CAMs.

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