Health Care Innovation Awards: Pennsylvania
Notes and Disclaimers:
- Projects shown may also be operating 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 are 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.
FINITY COMMUNICATIONS, INC.
Project Title: “EveryBODY Get Healthy”
Geographic Reach: Oregon, Pennsylvania
Funding Amount: $4,967,962
Estimated 3-Year Savings: $8.7 million
Summary: Finity Communications, Inc., is receiving an award to improve health care for high need populations in the greater Philadelphia area. The intervention will use health information technology to track and monitor over 120,000 at-risk patients, create a participant engagement program, develop integrated health profiles and care management plans, and evaluate and reassess treatment on a continuing basis. This comprehensive approach to health care is expected to reduce the total cost of care through prevention, maintaining wellness, and condition management with estimated savings of approximately $8.7 million. Over the three-year period, Finity Communications, Inc’s, program will train an estimated 13 health care workers and create an estimated 12 new jobs. These workers will support lifestyle change through prevention outreach and wellness education programs.
GEORGE WASHINGTON UNIVERSITY
Project Title: “Using Telemedicine in peritoneal dialysis to improve patient adherence and outcomes while reducing overall costs”
Geographic Reach: District of Columbia, Maryland, Pennsylvania, Virginia
Funding Amount: $1,939,127
Estimated 3-Year Savings: $1.7 million
Summary: George Washington University is receiving an award to improve care for about 300 patients on peritoneal dialysis in Washington, D.C., and eventually in Philadelphia and Southern Maryland. The intervention will use telemedicine to offer real-time, continuous, and interactive health monitoring to improve patient safety and treatment. The model will train a dialysis nurse workforce in prevention, care coordination, team-based care, telemedicine, and the use of remote patient data to guide treatment for co-morbid, complex patients. This approach is expected to improve patient access to care, adherence to treatment, self-management, and health outcomes, reducing cost of care for peritoneal dialysis patients with complex health care needs by reducing overall hospitalization days with estimated savings of approximately $1.7 million. Over the three-year period, George Washington University’s program will train an estimated three health care workers and create an estimated three new jobs. These workers will provide clinical support and health monitoring via the web to home dialysis patients.
INNOVATIVE ONCOLOGY BUSINESS SOLUTIONS, INC.
Project Title: “Community oncology medical homes (COME HOME)”
Geographic Reach: Florida, Georgia, Maine, New Mexico, Ohio, Pennsylvania, Tennessee
Funding Amount: $19,757,338
Estimated 3-Year Savings: $33,514,877
Summary: Innovative Oncology Business Solutions, Inc., representing 7 community oncology practices across the United States is receiving an award to implement and test a medical home model of care delivery for newly diagnosed or relapsed Medicare and Medicaid beneficiaries and commercially insured patients with breast, lung, or colorectal cancer. Cancer care is complicated, expensive, and often fragmented, leading to suboptimal outcomes, high cost, and patient dissatisfaction with care. Through comprehensive outpatient oncology care, including patient education, team care, medication management, and 24/7 practice access and inpatient care coordination, the medical home model will improve the timelines and appropriateness of care, reduce unnecessary testing, and reduce avoidable emergency room visits and hospitalizations.
Over a three-year period, Innovative Oncology Business Solutions will fill 115.6 new health care jobs, including positions for training specialists, data analysts, patient care coordinators, registered nurses, and licensed practical nurses, as well as for a finance manager and a compliance manager.
INSTITUTE FOR CLINICAL SYSTEMS IMPROVEMENT
Project Title: "Care management of mental and physical co-morbidities: a TripleAim bulls-eye"
Geographic Reach: California, Colorado, Iowa, 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 is receiving 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.
JOSLIN DIABETES CENTER, INC.
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: $7.4 million
Summary: Joslin Diabetes Center, Inc., is receiving 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 3000 Medicare and Medicaid beneficiaries and low income/uninsured populations 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 workers and health education instructors who will educate patients in managing diabetes and pre-diabetes.
PITTSBURGH REGIONAL HEALTH INITIATIVE
Project Title: Creating a Virtual Accountable Care Network for Complex Medicare Patients
Geographic Reach: Pennsylvania
Funding Amount: $10,419,511
Estimated 3-Year Savings: $74.1 million
Summary: Pittsburgh Regional Health Initiative is receiving 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 25,000 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 $74 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.
RUTGERS, THE STATE UNIVERSITY OF NEW JERSEY (THE CENTER FOR STATE HEALTH POLICY)
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, is receiving 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 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 filling prescriptions, finding housing or shelter, applying for health coverage or disability benefits, handling legal issues, finding transportation, treating depression, managing chronic illness, and coordinating appropriate specialty care. 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’ program will train an estimated 155 workers and will create an estimated 43 jobs. The new workforce will include community health workers.
THE TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Project Title: “A rapid cycle approach to improving medication adherence through incentives and remote monitoring for coronary artery disease patients”
Geographic Reach: New Jersey, Pennsylvania
Funding Amount: $4,841,221
Estimated 3-Year Savings: $2,787,030
Summary: The University of Pennsylvania is receiving an award for a program to improve medication adherence and health outcomes in post-discharge patients who are recovering from acute myocardial infarctions in metropolitan Philadelphia and adjoining areas of New Jersey. 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 telemonitoring and a visual and audible “reminder” system. It will also retrain social workers as engagement advisors to monitor adherence, offer incentives, and enlist patient support from family and friends. 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, the Trustees of the University of Pennsylvania’s program will train an estimated 21 workers, while creating an estimated seven jobs for investigators, clinical social workers, clinical nurses, software programmers, project co-directors, and a project director.
THE TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
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 are receiving an award to test a comprehensive set of home care services for Medicare and/or Medicaid beneficiaries with advanced cancer who are receiving skilled home care and have substantial palliative care needs, but are not yet eligible for hospice care. The program will serve five counties in the metropolitan Philadelphia area. Using care coordination and planning, the intervention will provide in-home support, symptom management, crisis management, and emotional and spiritual support for beneficiaries with advanced cancer, enabling them to remain in their homes and avoid unnecessary hospitalizations.
Over a three-year period, the Trustees of the University of Pennsylvania’s program will train an estimated 64 workers. It will create an estimated 16 jobs for home health aides, social workers, and licensed practical nurses.
UNIVERSITY OF NORTH TEXAS HEALTH SCIENCE CENTER
Project Title: "Brookdale Senior Living (BSL) Transitions of Care Program"
Geographic Reach: Alabama, Arizona, California, Colorado, Connecticut, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Nevada, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Washington, Wisconsin
Funding Amount: $7,329,714
Estimated 3-Year Savings: $9,729,702
Summary: The University of North Texas Health Science Center (UNTHSC), in partnership with Brookdale Senior Living (BSL), is receiving an award to expand and test the BSL Transitions of Care Program which is based on an evidenced-based assessment tool called Interventions to Reduce Acute Care Transfers (INTERACT) for residents living in independent living, assisted living and dementia specific facilities in Texas and Florida. In addition, community dwelling older adults who receive BSL home health services will be included in the Transitions of Care Program. Over the course of the award the program will expand to other states where BSL communities are located. The program will employ clinical nurse leaders (CNLs) to act as program managers. CNLs will train care transition nurses and other staff on the use of INTERACT and health information technology resources to help them identify, assess, and manage residents' clinical conditions to reduce preventable hospital admissions and readmissions. The goal of the program is to prevent the progress of disease, thereby reducing complications, improving care, and reducing the rate of avoidable hospital admissions for older adults.
Over a three-year period, the University of North Texas Health Science Center's program will train an estimated 10,926 workers and create an estimated 97 jobs for clinical nurse leaders and other health care team members.