Health Care Innovation Awards: Project Profile


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


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.

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