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.
MOUNTAIN AREA HEALTH EDUCATION CENTER
Project Title: “Regional integrated multi-disciplinary approach to prevent and treat chronic pain in North Carolina”
Geographic Reach: North Carolina
Funding Amount: $1,186,045
Estimated 3-Year Savings: $2,400,000
Summary: Mountain Area Health Education Center (MAHEC), serving 16 counties in western North Carolina, received an award to test team-based enhanced primary care for chronic pain patients. The project aims to improve patient outcomes and quality of care, increase community involvement and evidence-based clinical care training for providers, and reduce unintentional drug overdose rates. The test’s target population consists of over 2,000 patients. Clinical services commenced at MAHEC Family Health Center in January 2013, and an additional three sites will launch after July 2013. The intervention creates multidisciplinary teams to provide enhanced primary care, using mid-level and behavioral health providers to co-manage care with physicians. To support the three year goal of adding 7.5 regional healthcare positions, sites receive funding, specialty training and onsite consultation. To reduce prescription drug overdose rates, community coalition leaders in all sixteen counties have been selected. The project’s anticipated achievements are improved patient health and pain control, decreased outpatient visits, reduced unintentional drug overdose, and additional cost reductions of approximately $2.4 million.
NORTH CAROLINA COMMUNITY NETWORKS
Project Title: “Building a statewide child health accountable care collaborative: the North Carolina strategy for improving health, improving quality, reducing costs, and enhancing the workforce”
Geographic Reach: North Carolina
Funding Amount: $9,343,670
Estimated 3-Year Savings: $24,089,682
Summary: Community Care of North Carolina (CCNC) began a three year program in August 2012 called the Child Health Accountable Care Collaborative (CHACC) to improve the quality and cost-effectiveness of care associated with children who have complex, chronic illnesses. CCNC comprises fourteen local networks dispersed throughout the state of North Carolina. A fundamental component of this program is the use of an embedded Specialty Care Manager (SCM) whose primary role is to coordinate care between the pediatric subspecialist and the primary care physician (PCP). Theses SCMs are embedded in all five Academic Medical Centers (Carolinas Medical Center, Duke University, Vidant Medical Center, University of North Carolina, and Wake Forest Baptist Medical Center) as well as seven tertiary Medical Centers (Cape Fear Valley Medical Center, CMC Northeast, Mission Hospital, Moses Cone, New Hanover Regional Medical Center, Presbyterian Medical Center and Wake Med). The first SCMs began seeing patients in January 2013 after orientation and initial training. Patient Coordinators are also embedded, in collaboration with the SCMs, in medical centers with high volumes of children to assist the SCMs. A Patient Treatment Plan (PTP) was introduced to facilitate collaboration between pediatric subspecialists and PCPs. This PTP is updated by the SCMs during subspecialist visits or any hospitalization to ensure the PCP has the most current information needed to manage the child in a medical home environment. The CHACC Gastroenterology workgroup has also developed Co-Management Guidelines for Pediatric Constipation and GERD, which have been widely disseminated to the PCP group as well as residency programs throughout the state.
Project Title: "Integrating industrial and system engineering (ISE) methods into healthcare improvement"
Geographic Reach: Massachusetts, North Carolina, Washington
Funding Amount: $8,000,002
Estimated 3-Year Savings: $60,780,907
Summary: The Healthcare Systems Engineering Institute at Northeastern University received an award to conduct a National Demonstration Project of the value that the systems engineering methods used in other complex industries can also be used to reduce healthcare costs, improve quality and safety, reduce waits and delays, and improve clinical outcomes and overall population health. Under this award, Northeastern will create a model regional healthcare systems engineering extension center that partners with several local healthcare systems, applies systems engineering methods to targeted common problems to significantly impact the goals of better outcomes, better health, and at lower costs, and develops an implementation plan for national spread. This award funds the first phase of a larger scale 10-year project to establish a national network of similar healthcare systems engineering regional extension centers across the U.S. that develop and embed regional industrial and systems engineering improvement science academic departments and other resources into their local healthcare systems, saving billions annually while training a targeted future workforce of 15,000 healthcare systems engineers.
THE NATIONAL HEALTH CARE FOR THE HOMELESS COUNCIL
Project Title: “Community health workers and HCH: a partnership to promote primary care”
Geographic Reach: California, Illinois, Massachusetts, Nebraska, New Hampshire, North Carolina, Ohio, Texas
Funding Amount: $2,681,877
Estimated 3-Year Savings: $1,500,000
Summary: The National Health Care for the Homeless Council is working with twelve communities across various regions in the U.S. to reduce the number of emergency department visits and lack of primary care services for over 500 homeless individuals. The intervention integrates community health workers into Federally Qualified Health Centers to conduct outreach and case coordination for transitioning this population from the emergency department to a health center, thus reducing unnecessary emergency department visits and improving quality of care for this population. Over the three-year period, National Health Care for the Homeless Council’s program will train an estimated 101 health care workers, while creating an estimated 17 new jobs and saving approximately $1.0 million.
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.