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: “Comprehensive community-based approach to reducing inappropriate imaging”
Geographic Reach: Michigan
Funding Amount: $8,366,178
Estimated 3-Year Savings: $33,237,555
Summary: Altarum Institute, in partnership with United Physicians (IPA) and Detroit Medical Center Physician Hospital Organization, received an award to reduce unnecessary imaging studies for beneficiaries in Southeastern Michigan. This multifaceted intervention will establish a data-exchange system between primary care and imaging facilities to increase evidence-based decision-making among physicians ordering MRIs and CTs in the lumbar-spine, cervical-spine, lower extremities, shoulder, head, chest, and abdomen. The goal is to reduce CT volume by 17.4 percent and MRI volume by 13.4 percent over three years, resulting in a 17 percent reduction in imaging costs without any loss in diagnostic accuracy or restrictions on the ordering of tests. Over a three-year period, Altarum Institute will train a network of area care providers in the use of the program’s systems and technology, while creating an estimated 23 jobs for practice consultants, health information analysts, lean practice redesign specialists, and health education specialists.
FEINSTEIN INSTITUTE FOR MEDICAL RESEARCH
Project Title: “Using care managers and technology to improve the care of patients with schizophrenia”
Geographic Reach: Florida, Indiana, Michigan, Missouri, New Hampshire, New Mexico, New York, Oregon
Funding Amount: $9,380,855
Estimated 3-Year Savings: $10,080,000
Summary: The Feinstein Institute for Medical Research received an award to develop a workforce that is capable of delivering effective treatments, using newly available technologies, to at-risk, high-cost patients with schizophrenia. The intervention will test the use of care managers, physicians, and nurse practitioners trained to use new technology as part of the treatment regime for patients recently discharged from the hospital at community treatment centers in eight states. These trained providers will educate patients and their caregivers about pharmacologic management, cognitive behavior therapy, and web-based/home-based monitoring tools for their conditions. This intervention is expected to improve patients’ quality of life and lower cost by reducing hospitalizations. Over a three-year period, the Feinstein Institute for Medical Research will retrain nurse practitioners, physician assistants, physicians, and case managers to use newly available mental health protocols and health technology resources.
HENRY FORD HEALTH SYSTEM
Project Title: “Mobility: the 6th vital sign”
Geographic Reach: Michigan
Funding Amount: $3,773,539
Estimated 3-Year Savings: $8,837,501
Summary: The Henry Ford Health System (HFHS) of Detroit, Michigan received an award for an innovative care model that encourages and supports patient mobility for patients at risk for hospital –acquired pressure ulcers (HAPUs) and ventilator-associated pneumonia (VAP) during acute inpatient hospitalizations. The interventions include mobility and skin assessments, repositioning, range of motion exercises, assistance with ambulation and mobility/skin related patient and family education. The goal is to reduce HAPUs and associated costs, VAP, improve patient satisfaction and decrease length of stay.
Over a three-year period, HFHS will create approximately 20 jobs for health care providers, including a project manager, rehab therapists, wound care certified nurses and patient mobility assistants.
INSTITUTE FOR CLINICAL SYSTEMS IMPROVEMENT
Project Title: “Care management of mental and physical co-morbidities: a TripleAim bulls-eye"
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.
MICHIGAN PUBLIC HEALTH INSTITUTE
Project Title: “Michigan pathways to better health”
Geographic Reach: Michigan
Funding Amount: $14,145,784
Estimated 3-Year Savings: $17,498,641
Summary: The Michigan Public Health Institute (MPHI), in partnership with the Michigan Department of Community Health (MDCH) and local community agencies, implements the Michigan Pathways to Better Health (MPBH) initiative. MPBH supports the CMS goals of better health, better care, and lower cost by assisting beneficiaries to address social service needs and link them to preventative health care services.
MPBH is based on the Pathways Community HUB Model developed by Drs. Sarah and Mark Redding of the Community Health Access Project (CHAP). Community Health Workers (CHWs) are trained and deployed to assist Medicaid and/or Medicare adult beneficiaries with two or more chronic conditions with health and social service needs (such as primary care, housing, food, and transportation). In other states, the model has improved health outcomes and lowered healthcare costs.
Three high-need counties (and selected adjacent counties) are served: Ingham, Muskegon and Saginaw. In each county, a number of organizations work together to implement the model. The Lead Agency is the fiduciary, managing contracts and finances, and providing project oversight. Referrals to the program are made by healthcare providers, social service agencies, CHWs, and other community agencies. The Pathways Community HUB conducts outreach, accepts referrals, determines client eligibility, enrolls clients and assigns clients to a Care Coordination Agency (CCA). The HUB also manages the IT function, provides quality monitoring and improvement, and reports on outcomes to the CCAs and the community. CCAs deploy and manage the CHW workforce, receiving assignments from the HUB. Partners work together to identify, recruit, and train CHWs who live in the community. Before serving clients, CHWs receive training based on a curriculum developed by Dr. Sarah Redding. As CHWs work in the field, they are mentored by experienced CHWs and supervised by a registered nurse and/or social worker. CHWs do not provide direct healthcare or human services, but link clients to these services.
Over three years, MPBH will employ 75 CHWs and serve over 13,000 clients. The project will demonstrate the role of CHWs and Pathways Community HUBs in improving health outcomes and chronic disease management, while lowering healthcare costs by an estimated $17,498,641.
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.
TRUSTEES OF DARTMOUTH COLLEGE
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
Summary: 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.