Health Care Innovation Awards: Project Profile


Project Title: "Preventing hospitalizations in very high-risk patients"
Geographic Reach: Hawaii
Funding Amount: $5,299,706
Estimated 3-Year Savings: $10,393,944


Home Outreach Program & E-health (H.O.P.E.), supported by St. Francis Healthcare Foundation of Hawaii, received a Health Care Innovation Award from the Center of Medicaid and Medicare Services in June 2012. This initiative addresses healthcare costs associated with both hospitalizations and <30-day readmissions, with the goal of improving patient outcomes and reducing healthcare spending. The program consists of two high-risk groups: outpatients with complex health care needs identified by an algorithm and patients discharged from hospitals with the diagnosis of congestive heart failure, pneumonia, or acute myocardial infarction.  In the first group, Prevention of 1-Year Hospitalization, the emphasis will be on changing behavior, using home telehealth equipment with nurse clinician oversight as a reinforcing tool for patients to experience the impact of improved adherence with medications and other treatments.  In the second group, Prevent <30-Day Readmission, the focus will be on the transition to home of potentially unstable patients with the emphasis on the daily clinical measurements outlined in their physician's plan of care and supported by nurse clinician oversight. Data will be collected regularly to evaluate patient outcomes, patient and workforce satisfaction, and cost effectiveness of the program. The goal is to reduce preventable hospitalizations and readmissions by 40% as compared to a control group and to improve patients' health and quality of life.

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