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: “From clinic to community: achieving health equity in the southern United States”
Geographic Reach: Mississippi, North Carolina, West Virginia
Funding Amount: $9,773,499
Estimated 3-Year Savings: $20,800,000
Summary: Led by Duke University, the Southeastern Diabetes Initiative (SEDI) is a project that supports integrated teams implementing a model for improving health outcomes and quality of life for those suffering from type 2 diabetes mellitus (T2DM) in the Southeastern United States. The majority of funds are being used to (1) harvest data from all electronic sources in each county to create a comprehensive, integrated data warehouse to accurately reflect clinical and social data that can be represented at the individual, neighborhood, and community level, and (2) use that data to implement spatially-enabled informatics systems that risk stratify patients and neighborhoods, allowing implementation of an intense clinical intervention from a multi-disciplinary team that provides care to the highest risk patients as well as additional individual and neighborhood interventions to moderate risk patients and neighborhoods - providing real-time monitoring of individuals and populations with T2DM and serving as the basis for decision support and evaluation of interventions. A spatially-enabled analytical platform has been created via an electronic health record integrated data warehouse that covers the vast majority of Durham and Cabarrus County, North Carolina residents (representing urban and rural African Americans and Hispanics in North Carolina), Mingo County, West Virginia, and Quitman County, Mississippi (rural African Americans in the Mississippi Delta). Our collaborative team includes the Mississippi Institute for Public Health; Center for Rural Health at Joan C. Edwards School of Medicine, Marshall University; the Mingo County, West Virginia Diabetes Coalition and Williamson Health and Wellness Federally Qualified Health Center in Williamson, West Virginia; the Appalachian Regional Commission; the Durham County Department of Health in Durham, North Carolina; Duke University Medical Center; the Cabarrus Health Alliance in Kannapolis, North Carolina and Cabarrus Community Health Centers in Concord, North Carolina; and the National Center for Geospatial Medicine at the University of Michigan.
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.
UNIVERSITY OF ALABAMA AT BIRMINGHAM
Project Title: "Deep South Cancer Navigation Network (DSCNN)"
Geographic Reach: Alabama, Florida, Georgia, Mississippi, Tennessee
Funding Amount: $15,007,263
Estimated 3-Year Savings: $49,815,239
Summary: The University of Alabama at Birmingham (UAB) and the UAB Comprehensive Cancer Center received an award extending a regional network of lay health workers to expand comprehensive cancer care support services through a five state region. Working through the participating UAB Health System Cancer Community Network associate sites, the program seeks to create a national model for improving the quality of cancer care while decreasing unnecessary hospital utilization and enhancing patient satisfaction.
The program, named “Patient Care Connect,” is designed to serve Medicare beneficiaries with complex or advanced stage cancers, including those with psycho-social barriers to appropriate care, many living in medically underserved inner city and rural communities. Each navigation team will include an RN site manager and specially trained non-clinical patient navigators. The navigation teams will focus on helping patients by providing information about their cancer treatment, empowering patients to make informed choices about their care, providing emotional support and problem-solving, assisting with overcoming common barriers to cancer treatment, and helping patients make wise use of healthcare resources.
It is expected that the program will result in a reduction in emergency room visits and unnecessary hospital utilization, earlier acceptance of palliative and hospice services, better adherence to evidence based care plans, and an improved overall quality of life for cancer patients.
UNIVERSITY OF TENNESSEE HEALTH SCIENCE CENTER
Project Title: "Project SAFEMED"
Geographic Reach: Arkansas, Mississippi, Tennessee
Funding Amount: $2,977,865
Estimated 3-Year Savings: $3,160,844
Summary: The University of Tennessee Health Science Center, in partnership with Methodist LeBonheur Healthcare's Methodist North Hospital and Methodist South Hospital and community partners received an award to improve care transitions with an emphasis on medication management among high repeat utilizing patients in the northwest and southwest sections of Memphis, TN. The program will serve vulnerable adults (20-64) and seniors 65+ insured by Medicaid and/or Medicare who have multiple chronic diseases, including hypertension, diabetes, coronary artery disease, congestive heart failure, and chronic lung disease with presence of polypharmacy or high risk medications. Through multidisciplinary teams encompassing pharmacy, nursing, and social work based in outpatient centers, the program will enhance discharge planning, improve post-discharge outreach and follow-up, increase access to community based services and coordinate care across providers and settings. In addition, pharmacy technicians and licensed practical nurses will serve as outreach workers engaging patients through home visits, intense phone follow up, and group based support sessions. This approach will improve medication adherence to safe and effective medication regimens, overall chronic disease self-management, health services utilization patterns, and patient experience of care. Over a three-year period, the University of Tennessee Health Science Center's program will develop 5 new roles for direct care staff and create 11 jobs in the healthcare field.