Health Care Innovation Awards: Pennsylvania

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: “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: “EveryBODY Get Healthy”
Geographic Reach: Pennsylvania
Funding Amount: $4,967,962
Estimated 3-Year Savings: $8,700,000

Summary: The Finity Communications, Inc. model is designed to improve health care for over 120,000 high-need Medicaid beneficiaries in the Greater Philadelphia area. The innovation uses health analytics technology to track risk criteria and update integrated health profiles, and to deploy targeted alerts, outreach, wellness, and support services in a closed-loop environment that evolves with successful behavioral change. The innovation includes providing Peer Mentors to support ongoing engagement and healthy behavioral change. This integrated approach to health care is expected to reduce the gaps in care and lead to improved health care, better health, and reduced costs for individuals with diabetes, heart disease, hypertension, asthma, and high-risk pregnancy.


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.


Project Title: “Pathways to better health through a new health care workforce and community”
Geographic Reach: District of Columbia, New Mexico, Pennsylvania
Funding Amount: $4,967,276
Estimated 3-Year Savings: $7,400,000

Summary: Joslin Diabetes Center, Inc., received an award to expand a successful program for diabetes education, field testing, and risk assessment. Their “On the Road” program will send trained community health workers into community settings to help approximately 5100 unique participants (most of whom are Medicare/Medicaid beneficiaries and /or low income/uninsured) understand their risks and improve health habits for the prevention and management of diabetes. The program will target at risk and underserved populations in New Mexico, Pennsylvania, and Washington, D.C., helping to prevent the development and progression of diabetes and reducing overall costs, avoidable hospitalizations, and the development of chronic co-morbidities with estimated savings of approximately $7.4 million. Over the three-year period, Joslin Diabetes Center’s program will train an estimated 27 workers, while creating an estimated 9 new jobs. These workers will include community health advocates and health education instructors who will educate patients in managing diabetes and pre-diabetes with the goal of re-engaging them into the healthcare system.


Project Title: Creating a Virtual Accountable Care Network for Complex Medicare Patients
Geographic Reach: Pennsylvania, West Virginia
Funding Amount: $10,419,511
Estimated 3-Year Savings: $74,100,000

Summary: Pittsburgh Regional Health Initiative received an award for a plan to create specialized support centers, staffed by nurse care managers and pharmacists, to help small primary care practices offer more integrated care within the service areas of seven regional hospitals in Western Pennsylvania. The project will focus not only on approximately 19,000 Medicare beneficiaries with COPD, CHF, and CAD, but also the general primary care population of this area. The resulting teams will provide support for care transitions, intensive chronic disease management, medication adherence, and other problems associated with a lack of communication in health care systems at large and the resulting fragmentation of health care for patients. This approach is expected to reduce 30-day readmissions and avoidable disease-specific admissions with estimated savings of approximately $41 million. Over the three-year period, Pittsburgh Regional Health Initiative’s program will train an estimated 450 health care workers and create an estimated 26 new jobs. These workers will combine core competencies in the management of specific diseases with primary care support skills, and will be trained in evidence-based pathways of care.


Project Title: “Sustainable high-utilization team model”
Geographic Reach: California, Colorado, Missouri, Pennsylvania
Funding Amount: $14,347,808
Estimated 3-Year Savings: $67,719,052

Summary: Rutgers, The State University of New Jersey, received an award to expand and test a team-based care management strategy for high-cost, high-need, low-income populations served by safety-net provider organizations in Allentown, PA, Aurora, CO, Kansas City, MO, and San Diego, CA. Led by Rutgers Center for State Health Policy, the project will use integrated care management teams (including nurses, social workers, and community health workers) to provide clients with patient-centered support that addresses both health care needs and the underlying determinants of health. Teams will assist patients in managing chronic illness, including filling prescriptions and coordinating appropriate specialty care, in addition to addressing social service needs such as identifying stable housing, applying for health coverage or disability benefits and facilitating transportation arrangements. After patients are stabilized, the care management team will transition them to local primary care medical homes. By improving beneficiaries’ access to ambulatory medical and social services, the project will improve patient outcomes and reduce preventable hospital inpatient and emergency room utilization. Over a three-year period, Rutgers’s program will create an estimated 43 jobs across multiple health care professions.


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.


Project Title: “Comprehensive longitudinal advanced illness management (CLAIM)”
Geographic Reach: Pennsylvania
Funding Amount: $4,361,539
Estimated 3-Year Savings: $9,427,468

Summary: The Trustees of the University of Pennsylvania received an award to test a comprehensive set of home care services for patients with cancer who are receiving skilled home care and have substantial palliative care needs, but are not yet eligible for hospice care. The program serves five counties in the metropolitan Philadelphia area. Using care coordination and planning, the intervention provides in-home support, symptom management, crisis management, and emotional and spiritual support, enabling patients to remain in their homes and avoid unnecessary hospitalizations. Over a three-year period, the program will create an estimated 19 jobs for home health aides, social workers, nurses, and other clinical and administrative staff.

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