Notes and Disclaimers:
- Projects shown may also have operating 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.
FOUNDATION FOR CALIFORNIA COMMUNITY COLLEGES
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.
GEORGE WASHINGTON UNIVERSITY
Project Title: “Using Telemedicine in peritoneal dialysis to improve patient adherence and outcomes while reducing overall costs”
Geographic Reach: District of Columbia, Maryland, Virginia
Funding Amount: $1,939,127
Estimated 3-Year Savings: $1,700,000
Summary: George Washington University received an award to improve care for 300 patients on peritoneal dialysis in Washington, D.C., and eventually in Virginia and Maryland. The intervention will use telemedicine to offer real-time, continuous, and interactive health monitoring to improve patient safety and treatment. The model will train a dialysis nurse workforce in prevention, care coordination, team-based care, telemedicine, and the use of remote patient data to guide treatment for co-morbid, complex patients. This approach is expected to improve patient access to care, adherence to treatment, self-management, and health outcomes, while reducing cost of care for peritoneal dialysis patients with complex health care needs by reducing overall hospitalization days with estimated savings of approximately $1.7 million. Over the three-year period, George Washington University’s program will train an estimated three health care workers and create an estimated three new jobs. These workers will provide clinical support and health monitoring via the web to home dialysis patients.
JOSLIN DIABETES CENTER, INC.
Project Title: “Pathways to better health through a new health care workforce and community”
Geographic Reach: District of Columbia, New Mexico, Pennsylvania
Funding Amount: $4,967,276
Estimated 3-Year Savings: $7,400,000
Summary: Joslin Diabetes Center, Inc., received an award to expand a successful program for diabetes education, field testing, and risk assessment. Their “On the Road” program will send trained community health workers into community settings to help approximately 5100 unique participants (most of whom are Medicare/Medicaid beneficiaries and /or low income/uninsured) understand their risks and improve health habits for the prevention and management of diabetes. The program will target at risk and underserved populations in New Mexico, Pennsylvania, and Washington, D.C., helping to prevent the development and progression of diabetes and reducing overall costs, avoidable hospitalizations, and the development of chronic co-morbidities with estimated savings of approximately $7.4 million. Over the three-year period, Joslin Diabetes Center’s program will train an estimated 27 workers, while creating an estimated 9 new jobs. These workers will include community health advocates and health education instructors who will educate patients in managing diabetes and pre-diabetes with the goal of re-engaging them into the healthcare system.
MARY’S CENTER FOR MATERNAL CHILD CARE
Project Title: "Capital Clinical Integrated Network (CCIN)”
Geographic Reach: District of Columbia
Funding Amount: $14,991,005
Estimated 3-Year Savings: $17,712,000
Summary: Mary’s Center for Maternal Child Care in Washington, D.C. received an award to implement and test an integrated clinical network to improve care for high-utilizing chronically ill Medicaid recipients in the D.C. area, including those who rely on emergency room visits for primary health care. The project will use care teams and telemedicine to communicate with these patients, develop care plans for them, and personally manage their care as they are gradually transitioned into patient-centered medical homes. The result will be lower cost from reduced dependence on crisis care and ER visits and better health care for people with controllable chronic conditions such as diabetes, hypertension, asthma, and co-occurring mental illness. Over a three-year period, Mary’s Center for Maternal Child Care will hire and train 42 health care workers to serve as care managers and community-based care coordinators.