Health Care Innovation Awards: California

Notes and Disclaimers:

  • Projects shown may also have 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.


Project Title: “Patient Navigation Center”
Geographic Reach: California
Funding Amount: $2,684,545
Estimated 3-Year Savings: $3,373,602

Summary: Asian Americans for Community Involvement (AACI), in partnership with the Career Ladders Project and local community colleges, received an award to train Asian and Hispanic youth as non-clinical health workers for a Patient Navigation Center (PNC). Serving low-income Asian and Hispanic families in Santa Clara County, PNC will provide enabling services, including translation, appointment scheduling, referrals, and application help for social services, as well as after-hours and self-care assistance. Patient navigation will lead to improved access to care, better disease screening, decreased diagnosis time, better medication adherence, a reduction in emergency room visits, and reduced anxiety for patients. Over a three-year period, Asian Americans for Community Involvement will re-train its current staff of nurses, supervisors, and on-call clinicians and create an estimated 29 jobs. The new workers will include patient navigators, nurse and clinician advisors, and a workforce manager.


Project Title: “Care team integration of the home-based workforce”
Geographic Reach: California
Funding Amount: $11,831,445
Estimated 3-Year Savings: $24,957,836

Summary: The California Long-Term Care Education Center, in partnership with SEIU United Long Term Care Workers, Shirley Ware Education Center, SEIU United Healthcare Workers, L.A. Care Health Plan, Contra Costa Health Plan in conjunction with Contra Costa Employment and Human Services Department, SynerMed, St. John’s Well Child and Family Center, Care 1st Health Plan, and the University of California, San Francisco Center for Health Professions, is piloting an intervention project to integrate In-Home Supportive Services (IHSS) providers into the health care system. The project, titled Care Team Integration of the Home-Based Workforce, serves beneficiaries of California’s Medicaid personal care services program (known as IHSS). All beneficiaries are disabled and 85 percent are Medicare-Medicaid enrollees. Our project recognizes the unique position of personal home care aides (PHCAs) with respect to some of the sickest and most costly Medicare and Medicaid enrollees. In most cases, PHCAs are an untapped resource into the health care system. The program focuses on developing the IHSS workforce by training IHSS providers (or PHCAs) in core competencies that will enable them to serve as agents of change and assume new roles with respect to caring for their IHSS consumer. These core competencies include being health monitors, coaches, communicators, navigators, and care aides. The goal is to reduce ER visits by 23 percent and hospital admissions from the ER by 23 percent over three years. In addition, the project hopes to see a 10 percent reduction in the average length of stay in nursing homes over the same time period. Over a three-year period, the program will train an estimated 6,000 IHSS providers.


Project Title: “Prevention and Recovery in Early Psychosis (PREP)”
Geographic Reach: California
Funding Amount: $4,703,817
Estimated 3-Year Savings: $4,235,801

Summary: Family Service Agency of San Francisco expanded its Prevention and Recovery in Early Psychosis (PREP) to two low-income, largely Latino counties in Central and Northern California, San Joaquin (Stockton) and Monterey (Salinas). Schizophrenia is estimated to account for 2.5 to 3 percent of United States health care expenditures. Without an intervention like PREP, as many as 90 percent of the patients served would be Supplemental Security Income/Medicare recipients (up from 30 percent now) by the time they reached their 30s. Through evidence-based treatments, medication management, and care management, PREP aims to prevent the onset of full psychosis, and in cases in which full psychosis has already occurred, seeks to fully remit the disease and rehabilitate the cognitive functions it has damaged. Family Service Agency of San Francisco has trained over 20 health care providers to use their PREP intervention, while creating 19 jobs for social workers, Nurse Practitioners, vocational counselors, and peer and family aides.


Project Title: “Transitions clinic network:  linking high-risk Medicaid patients from prison to community primary care”
Geographic Reach: Alabama, California, Connecticut, District of Columbia, Maryland, Massachusetts, New York, Puerto Rico
Funding Amount: $6,852,153
Estimated 3-Year Savings: $8,115,855

Summary: City College of San Francisco (CCSF), University of California at San Francisco, and Yale University are collaborating to address the health care needs of high risk/high cost Medicaid and Medicaid-eligible individuals with chronic conditions released from prison. Targeting eleven community health centers in seven states and Puerto Rico, the program will work with the Department of Corrections to identify patients with chronic medical conditions prior to release and will use community health workers trained by City College of San Francisco to help these individuals navigate the healthcare system, find primary care and other medical and social services, and coach them in chronic disease management. The outcomes will include reduced reliance on emergency room care, fewer hospital admissions, and lower cost, with improved patient health and better access to appropriate care. Over a three-year period, this innovation will create an estimated 22 jobs and train an estimated 49 workers. The new workforce will include 12 community health workers, 11 part-time panel managers, two part-time project coordinators, one research analyst and two part-time project staff.


Project Title: "Patient-centered medical home for mental health services in Wyoming and Montana"
Geographic Reach: California, Montana, Washington, Wyoming
Funding Amount: $7,718,636
Estimated 3-Year Savings: $8,100,000

Summary: HealthLinkNow Inc, partnering with a number of local provider groups and health networks in Montana and Wyoming, is received an award to provide a Patient Centered Medical Home Program (PCMH) with mental health and substance abuse services in areas where geography and lack of psychiatrists and psychologists complicate access. This model will offer videoconferencing between local patients and HealthLinkNow psychiatrists; instant messaging, email, and telephone calls via HealthLinkNow between providers and patients; and a HealthLinkNow IT platform that allows billing, e-prescribing, and practice management. The program will improve access to psychiatric consultations, therapy, and long-term mental health case management. Lower costs through reduced hospital admissions and emergency room visits are anticipated. Over a three-year period, HealthLinkNow will hire 24 health care providers, including both psychiatrists and therapists.


Project Title: "Institute For Clinical Systems Improvement"
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.


Project Title: “Health Care Innovation Challenge: LifeLong complex care initiative to achieve the Triple Aim”
Geographic Reach: California
Funding Amount: $1,109,231
Estimated 3-Year Savings: $1,100,000

Summary: The LifeLong Complex Care Initiative merges the strengths of a community health center, LifeLong Medical Care, and an independent living center, Center for Independent Living, to provide coordinated, interdisciplinary team care for adults with disabilities who are at high-risk of poor health outcomes and avoidable utilization of high-cost emergency room and inpatient care. The project targets the 20% highest risk patients among a population of 3250 seniors and other adults with disabilities who are Medicaid and dual Medicare/Medicaid beneficiaries living in Alameda County, California and are members of the Alameda Alliance for Health. By the end of the three-year demonstration, the collaboration seeks to improve health outcomes and utilization patterns such that consumers are healthier, more satisfied with their care, and less likely to utilize high-cost services, with a goal of approximately $1 million in cost savings. The intervention trains adults with disabilities as peer coaches, to support consumers to identify and work towards self-directed health goals, such as healthy lifestyle modifications, disease self-management, and increased independence. The peer coaches are partnered with RN care managers, who facilitate integrated care and provide practical services including health education, medication reconciliation, and self-management support.


Project Title: "MedExpert International: Quality Medical Management System (QMMS)"
Geographic Reach: California, Idaho, Texas, Washington
Funding Amount: $9,332,545
Estimated 3-Year Savings: $50,410,304

Summary: MedExpert International received an award to test its Quality Medical Management System (QMMS) in comparison to a control group. QMMS is a shared decision-making system that provides consumers with access to world-expert physician advice, educational materials, and assistance with interpreting benefits and treatment options using Medical Information Coordinators and staff Physicians. QMMS will be available in selected geographic markets across the country to serve approximately 180,000 Medicare beneficiaries. The goal is to improve quality of care, reduce costs, increase transparency, achieve high utilization and satisfaction, and demonstrate model viability. Over a three-year period, MedExpert International will train and hire approximately 38 health care workers, including medical information coordinators, a medical information coordinator supervisor, a project manager, a senior executive manager, information technology and data engineers, senior engineers, and physicians.


Project Title: “Intensive outpatient care program”
Geographic Reach: Arizona, California, Washington
Funding Amount: $19,139,861
Estimated 3-Year Savings: $25,280,570

Summary: The Pacific Business Group on Health received its award to partner with provider groups in Arizona, California and Washington for the Intensive Outpatient Care Program (IOCP). Care managers embedded in primary care practices provide psychosocial and medical support for 27,000 predicted high-risk patients with chronic illness. The program aims to improve patient experience and clinical outcomes, reduce avoidable emergency room visits and hospitalizations, and spread best practices across a wide network of partners and, ultimately, other providers. Over a three-year period, Pacific Business Group on Health’s program will train over 410 people to spread best practices across a wide network, while creating an estimated 211 jobs for Care Coordinators and project staff.


Project Title: "Physicians quick response service”
Geographic Reach: California
Funding Amount: $4,254,615
Estimated 3-Year Savings: $3,229,481

Summary: Palliative Care Consultants of Santa Barbara received an award to provide health care services to the frail elderly in times of crisis. The name of their program is “DASH,” Doctors Assisting Seniors at Home. The intervention will create new options for frail elderly to access rapid assessment and treatment in their homes through a Rapid Response Team (RRT) dispatched to the homes of seniors who have fallen ill. This approach will reduce delays in care for the frail elderly and create lower exposure to hospitalization-related risks. Specially trained first responders will arrive within one hour to initiate the in-home assessment and triage process. The focus of this initiative is to provide active treatment to frail elderly patients in their home. The goal is to reduce emergency room visits and avoidable hospital admissions, increase patient satisfaction, and provide better, more immediate care through a system that is patient-centered and timely. Over a three-year period, Palliative Care Consultants of Santa Barbara’s program will train an estimated 32 workers and create an estimated 20 jobs. New workers will include physicians, first responders, a project manager, enrollment specialists, and an administrative assistant/communication specialist.


Project Title: “UCLA Alzheimer’s and dementia care: comprehensive, coordinated, patient-centered”
Geographic Reach: California
Funding Amount: $3,208,540
Estimated 3-Year Savings: $6,900,000

Summary: The UCLA Alzheimer’s and Dementia Care is a coordinated, comprehensive, patient and family-centered program with the aims of achieving better health, better care and lower cost of care for patients with dementia. The program has five key components: 1. patient recruitment and a dementia registry; 2. structured needs assessments of patients and their caregivers; 3. creation and implementation of individualized dementia care plans; 4. monitoring and revising care plans as needed; and 5. providing access 24/7, 365 days a year for assistance and advice. The program’s geographic focus is the Western area of Los Angeles County where we have established partnerships with five community-based organizations (CBOs) that serve dementia patients. Three geriatric nurse practitioners have been hired as Dementia Care Managers who perform patient needs assessments and monitoring, formulating and revising care plans with input from the program’s medical director and in partnership with the referring physician.


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.


Project Title: “Ravenswood Family Health Care Innovation Project"
Geographic Reach: California
Funding Amount: $7,302,463
Estimated 3-Year Savings: $6,200,000

Summary: South County Community Health Center, Inc. dba: Ravenswood Family Health Center (RFHC) in partnership with Health Plan of San Mateo, San Mateo County Behavioral Health and Recovery Services, Nuestra Casa and Voices of Recovery, is receiving an award to create a health care home for over 19,000 patient visits or 6,400 patients per year over three years living in our southeast San Mateo County, California service area. The majority of patients have diabetes, asthma, serious mental illness and other chronic conditions. The project will train paraprofessional Health Coach/Panel Managers that will, in a responsive and culturally appropriate manner, support and motivate patients to follow and adhere to evidence-based care plans. These Health Coach/Panel Mangers together with a Social Worker and Nurse Care Transition Coordinators will work with the provider to reduce (deleted space) avoidable emergency room visits,  hospital admissions and readmissions, and in overcoming barriers to obtain health and social support services with estimated savings of over $6 million. Over the three-year period, the South County Community Health Center, Inc. Ravenswood Family Health Innovation program will train an estimated 60 health care workers and create an estimated 28 new jobs.  These trained workers will support patient-centered medical teams that will manage a panel of patients that include identified high risk, high cost and high care utilizers.


Project Title: “Advanced Illness Management (AIM)"
Geographic Reach: California
Funding Amount: $13,000,000
Estimated 3-Year Savings: $29,388,894

Summary: Sutter Health is receiving an award to expand their Advanced Illness Management program (AIM) across the entire Sutter Health system in Northern California, serving patients who have severe chronic illness but are not ready for hospice care, are in clinical, functional, or nutritional decline, and are high-level consumers of health care. Such patients generally experience poor care quality, but account for a disproportionate share of Medicare spending. AIM addresses these issues through a complex medical home model that uses nurse-led interdisciplinary teams to coordinate and deliver care that encourages patient self-management of chronic illness that modifies disease course and provides symptomatic relief. The goals of the program are to improve care and patient quality of life, increase physician, caregiver, and patient satisfaction, and reduce Medicare costs associated with avoidable hospital stays, emergency room visits, and days spent in intensive care units and skilled nursing facilities.


Project Title: “Community health workers and HCH: a partnership to promote primary care”
Geographic Reach: California, Illinois, Massachusetts, Nebraska, New Hampshire, North Carolina, Ohio, Texas
Funding Amount: $2,681,877
Estimated 3-Year Savings: $1,500,000

Summary: The National Health Care for the Homeless Council is working with twelve communities across various regions in the U.S. to reduce the number of emergency department visits and lack of primary care services for over 500 homeless individuals. The intervention integrates community health workers into Federally Qualified Health Centers to conduct outreach and case coordination for transitioning this population from the emergency department to a health center, thus reducing unnecessary emergency department visits and improving quality of care for this population. Over the three-year period, National Health Care for the Homeless Council’s program will train an estimated 101 health care workers, while creating an estimated 17 new jobs and saving approximately $1.0 million.


Project Title: “Engaging patients through shared decision making: using patient and family activators to meet the triple aim”
Geographic Reach: California, Colorado, Idaho, Iowa, Maine, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, New York, Oregon, Texas, Utah, Vermont, Washington
Funding Amount: $26,172,439
Estimated 3-Year Savings: $63,798,577


The High Value Healthcare Collaborative (HVHC) received an award led by The Trustees of Dartmouth College to implement patient engagement and shared decision making processes and tools across its 15 member organizations for patients considering hip, knee, or spine surgery and complex patients with diabetes or congestive heart failure. The program will hire and train 48 health coaches across the 15 member organizations to engage patients and their families in their health care and health decisions.

High Value Healthcare Collaborative (HVHC) is implementing a bundle of services related to the care of sepsis patients across 13 health care systems around the country. The overall goal of this project is to utilize process improvement strategies to implement specific services at 3- and 6-hours post diagnosis as defined by the Surviving Sepsis Campaign (SSC) and National Quality Forum (NQF) guidelines for the care of severe sepsis or septic shock. Over three years, this intervention aims to improve optimal adherence to sepsis bundled care by 5%, reduce the burden of chronic morbidity from sepsis-associated chronic organ dysfunction, and achieve a 5% relative rate reduction in the number of patients with sepsis requiring long-term acute care or sub-acute nursing care after an incident episode of severe sepsis.


Project Title: “Cost-effective delivery of enhanced home caregiver training”  
Geographic Reach: Arkansas, California, Hawaii, Texas
Funding Amount: $3,615,818
Estimated 3-Year Savings: $1,286,251

Summary: The University of Arkansas for Medical Sciences received an award for enhanced training of both family caregivers and the direct-care workforce in order to improve care for elderly patients requiring long-term care services, including Medicare beneficiaries qualifying for home healthcare services and Medicaid beneficiaries who receive homemaker and personal care assistant services. Inadequate training of the direct care worker has been shown to have a direct impact on the quality of care to the elderly. By enhancing the training of the direct-care workforce, the increasingly complex care needs of the older adult can be better managed in the home, leading to fewer avoidable hospital admissions and readmissions, better preventive care, better compliance with care, and avoidance of unnecessary institutional care. The investments made by this grant are expected to generate cost savings beyond the three year grant period. Over a three-year period, The University of Arkansas for Medical Sciences’ program will train an estimated 2,100 workers and will create an estimated four jobs. The new workforce will include a project manager, a nurse educators and an administrative assistant. Additionally, this program will train home care givers in rural areas using distance education. Through tuition and textbook support in the form of microcredit loans, this program will increase the number of certified caregivers providing direct care to elderly adults.


Project Title: "Integrating clinical pharmacy services in safety-net clinics”
Geographic Reach: California
Funding Amount: $12,007,677
Estimated 3-Year Savings: $43,716,000


The University of Southern California aims to improve healthcare quality, enhance medication safety, and reduce overall healthcare costs for high-risk, underserved populations. These aims will be achieved by: 1) integrating comprehensive clinical pharmacy services in patient-centered medical homes, and 2) spreading the services to other organizations through workforce development and web-based two-way communication.

The model is serving the underserved and vulnerable populations of Santa Ana, Huntington Beach, and Garden Grove. The selected area represents the epicenter of uncontrolled chronic disease - almost half the population is foreign born and 47% of the population lives below 200% of the Federal Poverty Level (FPL). Providing comprehensive medication management and drug safety protocols to these chronically-ill populations is expected to reduce overall treatment costs and achieve net cost savings.

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