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.
BRONX REGIONAL HEALTH INFORMATION ORGANIZATION (BRONX RHIO)
Project Title: “The Bronx Regional Informatics Center (BRIC)”
Geographic Reach: New York
Funding Amount: $12,839,157
Estimated 3-Year Savings: $15,419,460
Summary: The Bronx Regional Health Information Organization (Bronx RHIO), in partnership with its member organizations and Bronx Community College, Weill Cornell Medical College, Optum Data Management, and the Emergency Health Information Technology group at Montefiore Medical Center, received an award to create the Bronx Regional Informatics Center, which will develop data registries and predictive systems that will proactively encourage early care interventions and enable providers to better manage care for high-risk, high-cost patients. The project will improve patient outcomes, improve overall health for Bronx residents, reduce the cost of care for Medicare and Medicaid by over $15 million, and train health care workers to coordinate these quality improvement efforts.
Over a three-year period, The Bronx RHIO will create an estimated 30 jobs, including positions for intervention team members and community health advocates.
DEVELOPMENTAL DISABILITIES HEALTH SERVICES
Project Title: “Expanding and testing a Nurse Practitioner-led health home model for individuals with developmental disabilities”
Geographic Reach: Arkansas, New Jersey, New York
Funding Amount: $3,701,528
Estimated 3-Year Savings: $5,374,080
Summary: Developmental Disabilities Health Services received an award to test a developmental disabilities health home model using care management/primary care teams of nurse practitioners and MDs to improve the health and care of persons with developmental disabilities in important clinical areas. This health home model serves individuals with intellectual and developmental disabilities who receive Medicaid and/or Medicare benefits in New Jersey, the Bronx, and Little Rock, Arkansas, and are eligible for services in each state's Home- and Community-Based Services waiver program, as well as individuals who are commercially insured and uninsured. All of the patients are considered high-risk and many have co-morbidities. By integrating care using nurse practitioners as care coordinators and health care providers, the health homes are improving primary care, mental health care, basic neurological care, and seizure management for these beneficiaries, resulting in reduced emergency room visits and lower out-of-home placement and institutionalization. Over a three-year period, Developmental Disabilities Health Services will retrain and deploy 20 individuals to provide and coordinate primary care and mental health services in health homes for persons with developmental disabilities.
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.
FINGER LAKES HEALTH SYSTEM AGENCY
Project Title: “Transforming primary care delivery: a community partnership”
Geographic Reach: New York
Funding Amount: $26,583,892
Estimated 3-Year Savings: $48,021,083
Summary: Finger Lakes Health Systems Agency (FLHSA) received an award to enhance primary care in the Finger Lakes region of New York State. Focusing on primary care practices with large panels of adult Medicare and Medicaid patients, selected participants will receive a fully-funded care manager, technical and financial assistance towards patient-centered medical home certification, and inclusion in an innovative payment model developed in collaboration with local payers. The primary goal of these supports is to reduce hospital admissions, hospital readmissions, and emergency department usage. Over a three year period, the FLHSA will select sixty-five primary care practices, fund and train over seventy-five healthcare professionals, and establish reimbursement methods sustain these activities past the grant timeframe.
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.
FUND FOR PUBLIC HEALTH IN NEW YORK
Project Title: "Parachute NYC: an alternative approach to mental health treatment and crisis services"
Geographic Reach: New York
Funding Amount: $17,608,085
Estimated 3-Year Savings: $51,696,138
Summary: The Fund for Public Health in New York, Inc., in partnership with the New York City Department of Health and Mental Hygiene’s Division of Mental Hygiene, received an award to implement Parachute NYC, a citywide approach to provide a “soft-landing” for individuals experiencing psychiatric crisis. This new program offers community centered options that focus on recovery, hope — and a healthy future. Parachute NYC uses mobile treatment teams, crisis respite centers, and a peer operated Support Line to provide early engagement (including a dedicated program for first episode psychosis), continuity of care and combined peer and non-peer community service, thus shifting the focus of care from crisis intervention to long-term, community-integrated treatment with access to primary care, improving crisis management and reducing emergency room visits and hospital admissions. Parachute NYC serves communities in Manhattan, Brooklyn, Bronx, and Queens.
MAIMONIDES MEDICAL CENTER
Project Title: “Brooklyn Care Coordination Consortium”
Geographic Reach: New York
Funding Amount: $14,842,826
Estimated 3-Year Savings: $41,759,040
Summary: Maimonides Medical Center of Brooklyn, New York, is pioneering improvements in care for adults with serious mental illness who live in southwest Brooklyn. In partnership with a broad array of medical, mental health, and social service organizations, insurers, and a labor union, Maimonides is: 1) providing enrolled patients with a core multi-disciplinary care team; 2) enabling medical and mental health providers to communicate with each other and monitor patients through advanced health information technology tools; 3) training a workforce of care managers and care navigators; 4) implementing uniform care standards; and 5) enhancing coordination of care through use of a web-based, electronic care plan. Maimonides expects this approach to reduce psychiatric and medical hospital admissions and reduce the total cost of care for the population, while creating approximately 50 new jobs, focused primarily in care management roles. At the same time, Maimonides is working to transition the reimbursement model for this population from “fee for service” to an integrated “total cost of care” through new, innovative financial arrangements with payers that build sustainability of the program beyond the three-year period of the Innovation Award.
Project Title: “Patient-centric electronic environment for improving acute care performance”
Geographic Reach: Massachusetts, Minnesota, New York, Oklahoma
Funding Amount: $16,035,264
Estimated 3-Year Savings: $81,345,987
Summary: The Mayo Clinic received an award to improve critical care performance for Medicare and Medicaid beneficiaries in intensive care units (ICUs). The goal of this project is to develop and test a novel acute care interface with built-in-tools for error prevention, practice surveillance, decision support and reporting (ProCCESs AWARE - Patient Centered Cloud-based Electronic System: Ambient Warning and Response Evaluation). In preliminary studies, these novel informatics support builds on advanced understanding of cognitive and organizational ergonomics, have significantly decreased cognitive load of bedside providers and reduced medical errors. Using a cloud-based technology, AWARE will be uniformly available on either mobile or fixed computing devices and applied in a standardized manner in medical and surgical ICUs of geographically diverse acute care hospitals predominantly serving Medicare and Medicaid patients. The impact of ProCCESs AWARE on processes of care and outcomes in study ICUs will be evaluated using standardized step-wedge cluster randomized study design expected to enroll more than 10,000 critically ill patients during the three year study period. Over a three-year period, the Mayo Clinic will train 1440 existing ICU caregivers in four diverse hospital systems to use new health information technologies effectively in managing ICU patient care.
MOUNT SINAI SCHOOL OF MEDICINE
Project Title: "Geriatric emergency department innovations in care through workforce, informatics, and structural enhancements (GEDI WISE)"
Geographic Reach: Illinois, New Jersey, New York
Funding Amount: $12,728,753
Estimated 3-Year Savings: $40,124,805
Summary: The Icahn School of Medicine at Mount Sinai received an award to implement a new model of geriatric emergency care in three large, urban hospitals: The Mount Sinai Medical Center in New York City, St. Joseph’s Regional Medical Center in Paterson, NJ, and Northwestern Memorial Hospital in Chicago, IL. Geriatric Emergency Department Innovations in care through Workforce, Informatics and Structural Enhancements (GEDI WISE) is a multidisciplinary collaboration that has embraced a new care paradigm, the geriatric emergency department, which has transformed both the physical environment and processes of care in these three emergency departments (ED). GEDI WISE uses evidence-based geriatric clinical protocols, informatics support for patient monitoring and clinical decision-making, and structural enhancements to improve patient safety and satisfaction while decreasing hospitalizations, return ED visits, unnecessary diagnostic and therapeutic services, medication errors, and adverse events, such as falls and avoidable complications. Over a three-year period, GEDI WISE will train more than 400 current health care workers and create 22 new jobs including nurses, nurse practitioners, pharmacists, physical therapists, project coordinators, data analysts and geriatric transitional care managers.
NATIONAL COUNCIL OF YOUNG MEN'S CHRISTIAN ASSOCIATIONS OF THE UNITED STATES OF AMERICA (YMCA OF THE USA)
Project Title: "Delivery on the promise of diabetes prevention programs"
Geographic Reach: Arizona, Delaware, Florida, Indiana, Minnesota, New York, Ohio, Texas
Funding Amount: $11,885,134
Estimated 3-Year Savings: $4,273,807
Summary: The National Council of Young Men's Christian Associations of the United States of America (Y-USA), in partnership with 17 local Ys currently delivering the YMCA’s Diabetes Prevention Program, the Diabetes Prevention and Control Alliance, and 7 other leading national non-profit organizations focused on health and medicine, is serving prediabetic Medicare beneficiaries in 17 communities across 8 states in the U.S. The intervention delivers community-based diabetes prevention through a nationally-recognized diabetes prevention lifestyle change program, coordinated and taught by trained YMCA Lifestyle Coaches. The goal is to prevent the progression of prediabetes to diabetes, which will improve health and decrease costs associated with complications of diabetes, hypercholesterolemia, and hypertension. The investments made by this grant are expected to generate cost savings beyond the three year grant period. Over a three-year period, Y-USA and its partners will train an estimated 1500 workers and create an estimated eight jobs. The new jobs will include communication specialists, a program manager, a grant administrator, a workforce development manager, data specialists, training specialists, and administrative coordinator.
THE TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Project Title: “A rapid cycle approach to improving medication adherence through incentives and remote monitoring for coronary artery disease patients”
Geographic Reach: Delaware, New Jersey, New York, Pennsylvania
Funding Amount: $4,841,221
Estimated 3-Year Savings: $2,787,030
Summary: The University of Pennsylvania received an award for a program to improve medication adherence and health outcomes in patients who have recently been discharged from the hospital with acute myocardial infarction. Such patients typically have high rates of poor medication adherence and hospital readmissions and are costly to monitor through intensive case management. The intervention will increase medication adherence through remote monitoring, medication reminders, incentives, and support from family and friends. It will also retrain social workers as engagement advisors to provide additional support as needed. The result will be improved health outcomes and lower cost. The investments made by this grant are expected to generate cost savings beyond the three year grant period. Over a three-year period, University of Pennsylvania’s program will train an estimated 21 workers, while creating an estimated seven jobs for investigators, clinical social workers, a software developer, project coordinators, and a project director.
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.
UNIVERSITY EMERGENCY MEDICAL SERVICES
Project Title: “Better health through social and health care linkages beyond the emergency department”
Geographic Reach: New York
Funding Amount: $2,570,749
Estimated 3-Year Savings: $6,100,000
Summary: University Emergency Medical Services, a physician practice plan affiliated with the Department of Emergency Medicine at the University at Buffalo, and in partnership with Erie County Medical Center (ECMC), is deploying community health workers to work with frequent emergency department (ED) utilizers and meaningfully link them to primary care, social and health services, education, and provide health coaching. The program targets 2,300 Medicare and Medicaid beneficiaries who have had two or more emergency department visits over 12 months in urban Buffalo, New York. Patients are recruited in the emergency department and referred by the ECMC Primary Care Clinics and other hospital affiliated programs. These patients account for 29% of all ED patients and 85% of all hospital inpatients are admitted through the hospital’s emergency department. Health coaching and improved access to primary care is expected to result in lower ER utilization, reduced hospital admissions, and improved health with estimated savings of approximately $6.1 million. Over the three year period, University Emergency Medical Service's program will train an estimated 13 health care workers and create an estimated 13 new jobs.