Health Care Innovation Awards: Maryland

Notes and Disclaimers:

  • Projects shown may have also 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: “Expand Atlantic General Hospital’s infrastructure to create a patient-centered medical home”
Geographic Reach: Delaware, Maryland
Funding Amount: $1,097,512
Estimated 3-Year Savings: $3,522,000

Summary: Atlantic General Hospital Corporation, which serves largely rural Worcester County, Maryland, is working to improve care for Medicare beneficiaries through a patient centered medical home (PCMH) care model. Through a partnership with the Worcester County Health Department (WCHD), Atlantic General has implemented PCMH standards and principles in all seven of its primary care practices, increasing access for patients needing non-emergency episodic care to reduce hospital admission rates and emergency department visits for these Medicare beneficiaries. The original intent of the grant-funded project was to focus on patients with either a primary or admitting diagnosis of congestive heart failure, chronic obstructive pulmonary disease (COPD), or diabetes, who currently rely on high-cost ER visits and acute care admissions. However, the PCMH team has been able to expand the program to offer services to patients with additional diagnoses.


Project Title: "Medicare and CareFirst’s total care and cost improvement program in Maryland”
Geographic Reach: Maryland
Funding Amount: $24,000,000
Estimated 3-Year Savings: $29,213,838

Summary: CareFirst BlueCross BlueShield received an award to expand its Total Care and Cost Improvement Program (TCCI), which includes its Patient-Centered Medical Home to approximately 25,000 Medicare beneficiaries in Maryland. This approach will move the region toward a new health care financing model that is more accountable for care outcomes and less driven by the volume-inducing aspects of fee-for-service payment. The TCCI Program will enhance support for primary care, empowering primary care providers to coordinate care for Medicare beneficiaries with multiple morbidities and patients at high risk for chronic illnesses. TCCI will result in less fragmented health care, reducing avoidable hospitalizations, emergency room visits, medication interactions, and other problems caused by gaps in care and ensuring that patients receive the appropriate care for their conditions. The TCCI Program will create an estimated 36 jobs. The new workforce will include local care coordinators, and program consultants.


Project Title: “Bridging the Divides”
Geographic Reach: Delaware, Maryland, New Jersey, Pennsylvania
Funding Amount: $9,999,999
Estimated 3-Year Savings: $376,327

Summary: Christiana Care Health System, serving the state of Delaware, received an award to create and test a system that uses a ”care management hub” and combines information technology and carefully coordinated care management to improve care for post-myocardial infarction and revascularization patients, the majority of them Medicare or Medicaid beneficiaries. Christiana Care will integrate statewide health information exchange data with cardiac care registries from the American College of Cardiology and the Society of Thoracic Surgeons, enabling more effective care/case management through near real time visibility of patient care events, lab results, and testing. This will decrease emergency room visits and avoidable readmissions to hospitals and improve interventions and care transitions. The investments made by this grant are expected to generate cost savings beyond the three year grant period. Over a three-year period, Christiana Care Health System will create an estimated 16 health care jobs, including positions for nurse care managers, pharmacists, and social workers.


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: "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.


Project Title: "CAPABLE for frail dually eligible older adults: achieving the triple aim by improving functional ability at home”
Geographic Reach: Maryland
Funding Amount: $4,093,356
Estimated 3-Year Savings: $6,800,000

Summary: The Johns Hopkins School of Nursing received an award for a Medicare/Medicaid dual eligibles program (Community Aging in Place, Advancing Better Living for Elders –“CAPABLE”) that uses a care management team to improve the everyday functioning of complex, frail patients in their own homes. The program will reduce difficulty with activities of daily living and improve medication management, mobility, and health-related quality of life, based on an individualized package of interventions including home visits from occupational therapists and nurses and other services.CAPABLE will reduce nursing home admissions and hospitalizations and improve quality of life for these beneficiaries of Medicare and Medicaid. Over a three-year period, the John Hopkins School of Nursing will retrain an estimated eight occupational therapists and registered nurses and as well as engage other services.


Project Title: "Johns Hopkins Community Health Partnership (J-CHiP)"
Geographic Reach: Maryland
Funding Amount: $19,920,338
Estimated 3-Year Savings: $52,600,000

Summary: Johns Hopkins University, in partnership with Johns Hopkins Health System and its hospitals, community clinics and other affiliates, the Johns Hopkins Urban Health Institute, Priority Partners MCO, Baltimore Medical System (BMS) - a Federally Qualified Health Center, and local skilled nursing facilities, received an award to create a comprehensive and integrated program, the Johns Hopkins Community Health Partnership (J-CHiP). J-CHiP is designed to increase access to services for high-risk adults in East Baltimore, MD, especially those with chronic illness, mental illness, and/or substance abuse conditions. The intervention improves care coordination across the continuum and comprises early risk screening, interdisciplinary care planning, enhanced medication management, patient/family education, provider communication, post-discharge support and home care services, including self-management coaching, and improved access to primary care. The program will target inpatients at The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center, expanding to nearly all adult admissions by the end of year 3. The intervention will also include a specific focus on high risk Medicare and Medicaid beneficiaries who receive primary care from Johns Hopkins clinics and a BMS clinic adjacent to these hospitals. The program will reduce avoidable hospitalizations, emergency room use, and complications and increase access to care and other services. Over a three-year period, Johns Hopkins University will train and hire more than 75 new health care workers, including nurse educators, nurse transition guides, case managers, community health workers, and health behavior specialists, and will retrain care coordinators, patient access line case managers, clinical pharmacy specialists, community health workers, and physicians already on staff.


Project Title: “Multi-community partnership between TransforMED, hospitals in the VHA system and a technology/data analytics company to support transformation to PCMH of practices connected with the hospitals and development of “Medical Neighborhood”
Geographic Reach: Alabama, Connecticut, Florida, Georgia, Indiana, Kansas, Kentucky, Maryland, Massachusetts, Michigan, Mississippi, Nebraska, North Carolina, Oklahoma, South Dakota, West Virginia
Funding Amount: $20,750,000
Estimated 3-Year Savings: $52,824,000

Summary: TransforMED received an award for a primary care redesign project across 15 communities to support care coordination among Patient-Centered Medical Homes (PCMH), specialty practices, and hospitals, creating “medical neighborhoods.” The project will use a sophisticated analytics engine, provided by a vendor, Phytel, to identify high risk patients and coordinate care across the medical neighborhood while driving PCMH transformation in a number of primary care practices in each community. Truly comprehensive care will improve care transitions and reduce unnecessary testing, leading to lower costs with better outcomes. TransforMED will work with VHA to capture learnings from leading performers. Cost trends will be identified via claims data using an analytic tool provided by a vendor, Cobalt Talon. Over a three-year period, TransforMED’s program will train an estimated 3,024 workers and create an estimated 22 jobs.

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