Health Care Innovation Awards: Project Profile


Project Title: "Transitional care teams to improve quality and reduce costs for rural patients with complex illness"
Geographic Reach: Iowa
Funding Amount: $7,662,278
Estimated 3-Year Savings: $12,500,000


The University of Iowa, in partnership with 10 Critical Access Hospitals (CAHs), is improving care coordination and communication with practitioners in nine rural Iowa counties. The program serves adults in these counties and selected contiguous catchment areas in which a CAH serves large numbers of patients. Adults are served without regard to whether they are Medicare, Medicaid, Medicare/Medicaid dual-eligible beneficiaries privately insured or uninsured. The aim is to assist adults with complex illness being discharged from the University of Iowa Hospitals & Clinics from psychiatric and internal medicine departments. Their complex issues may include psychiatric disorders, heart disease, kidney disease, endocrine and gastrointestinal disorders, pulmonary and geriatric issues. The program coordinates care through teams comprised of nurses, social workers, and pharmacists along with specialty physicians (including psychiatrists) using a care coordination protocol that informs, facilitates and ensures post discharge care and incorporating telehealth and web-based personal health records. The program is based on the University of Iowa's significant past experience in care coordination and creating telehealth care teams for patients with diabetes, chronic obstructive pulmonary disease, and heart failure. It will increase access to services and specialty care, improve care transitions and care coordination, and decrease avoidable hospital readmissions of complex patients in rural counties in Iowa.

Over a three-year period, the University of Iowa's program will train an estimated 22 workers and will create an estimated 28 jobs. The new hires will include 10 community care coordinators, two project managers, a program secretary, an outcomes analyst, a qualitative analyst, a database manager, nurse team leaders, social workers, and an informatics director.

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