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, Illinois, Indiana, Kansas, Kentucky, Maryland, Massachusetts, Michigan, Mississippi, Nebraska, Oklahoma, South Dakota, West Virginia
Funding Amount: $20,750,000
Estimated 3-Year Savings: $52,824,000
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.