Health Care Innovation Awards: California
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.
ASIAN AMERICANS FOR COMMUNITY INVOLVEMENT
Project Title: “Patient Navigation Center”
Geographic Reach: California
Funding Amount: $2,684,545
Estimated 3-Year Savings: $3,373,602
Summary: Asian Americans for Community Involvement (AACI), in partnership with the Career Ladders Project and three community colleges is receiving an award to train Asian and Hispanic youth and veteran AACI case workers as non-clinical health workers for a Patient Navigation Center. Serving low-income Asian and Hispanic families in Santa Clara County, the Center will provide enabling services, including translation, appointment scheduling, referrals, transportation, and application help for social services, as well as after-hours and self-care assistance. Patient navigation will lead to improved access to care, better disease screening, decreased diagnosis time, better medication adherence, a reduction in emergency room visits, and reduced anxiety for patients.
Over a three-year period, Asian Americans for Community Involvement will retrain its current staff of nurses, supervisors, and on-call clinicians and create an estimated 29 jobs. The new workers will include patient navigators, nurse and clinician advisors, and a customer service manager.
CALIFORNIA LONG-TERM CARE EDUCATION CENTER
Project Title: “Care team integration of the home-based workforce”
Geographic Reach: California
Funding Amount: $11,831,445
Estimated 3-Year Savings: $24,957,836
Summary: The California Long-Term Care Education Center, partnering with SEIU United Long Term Care Workers (ULTCW), Shirley Ware Education Center (SEIU-UHW), L.A. Care Health Plan, Contra Costa County Department of Aging and Health Services, Health Plan of San Mateo and the UCSF Center for Health Professions, is receiving an award to integrate personal care attendants into the health care system. This intervention will serve beneficiaries of California’s Medicaid personal care services program, the In-Home Support Services (IHSS). All beneficiaries are disabled and 85 percent are dually eligible for both Medicare and Medicaid. The program will train In-Home Supportive Services (IHSS) personal and home care attendants (PHCAs) to assume key roles in the patient’s health, including health monitor, coach, communicator, navigator, and care aide. The goal is to reduce ER visits by 23 percent and hospital admissions from the ER by 23 percent over three years. In addition, the project hopes to see a 10 percent reduction in the average length of stay in nursing homes over the same time period.
Over a three-year period, the California Long-Term Care Education Center’s program will train an estimated 6,900 health care workers.
FAMILY SERVICE AGENCY OF SAN FRANCISCO
Project Title: “Prevention and Recovery in Early Psychosis (PREP)”
Geographic Reach: California
Funding Amount: $4,703,817
Estimated 3-Year Savings: $4,235,801
Summary: Family Service Agency of San Francisco is receiving an award to expand and test its model for Prevention and Recovery in Early Psychosis (PREP) for low-income, largely Latino counties in the San Francisco area. Schizophrenia is estimated to account for 2.5 to 3 percent of United States health care expenditures. Without an intervention like PREP, as many as 90 percent of the patients served would be Supplemental Security Income/Medicare recipients (up from 30 percent now) by the time they reached their 30s. Through evidence-based treatments, medication management, and care management, PREP aims to prevent the onset of full psychosis, and in cases in which full psychosis has already occurred, seeks to fully remit the disease and rehabilitate the cognitive functions it has damaged.
Over a three-year period, the Family Service Agency of San Francisco will train 56 health care providers to use their PREP intervention, while creating 19 jobs for social workers, Nurse Practitioners, vocational counselors, and peer and family aides.
INSTITUTE FOR CLINICAL SYSTEMS IMPROVEMENT
Project Title: "Institute For Clinical Systems Improvement"
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.
LIFELONG MEDICAL CARE
Project Title: “Health Care Innovation Challenge: LifeLong complex care initiative to achieve the Triple Aim”
Geographic Reach: California
Funding Amount: $1,109,231
Estimated 3-Year Savings: $1.1 million
Summary: LifeLong Medical Care is receiving an award to further integrate care and encourage healthy behavior, among 3250 seniors and other adults with disabilities who are Medicaid and dual Medicare/Medicaid-eligible beneficiaries. The goal is to reduce avoidable emergency room and hospital visits. The intervention will train adults with disabilities to support adoption of healthy behaviors among their peers and to encourage self management, with the support of a team of nurse care managers. Improved care and better health for these high risk patients will lower costs with estimated savings of approximately $1 million. Over the three-year period, LifeLong Medical Care’s program will train an estimated 60 health care workers, while creating an estimated 60 new jobs. These workers will include peer health coaches and nurse care managers who will facilitate integrated care for seniors and for low-income adults with disabilities. LifeLong will partner with Berkeley’s Center for Independent Living and the Alameda Alliance for Health to achieve program goals.
PACIFIC BUSINESS GROUP ON HEALTH
Project Title: “Intensive outpatient care program”
Geographic Reach: California
Funding Amount: $19,139,861
Estimated 3-Year Savings: $25,280,570
Summary: The Pacific Business Group on Health is receiving an award to work with various provider groups and health plans in rural and urban counties throughout the States of Arizona and California to improve care coordination for 30,000 Medicare and dual-eligible Medicare-Medicaid beneficiaries at risk from multiple chronic conditions. This model will use care managers embedded in primary care practices, payment reforms, and active learning networks to help build infrastructure and spread best practices among a wide set of providers. The goal is fewer emergency room visits, a reduction in avoidable hospitalizations, better mitigation of disease, and reduced complications as a result of intensive care management.
Over a three-year period, Pacific Business Group on Health’s program will train over 410 people, while creating an estimated 211 jobs for Registered Nurses, project managers, a project director, a clinical director, a grants manager, information technology analysts, and administrative support staff.
PALLIATIVE CARE CONSULTANTS OF SANTA BARBARA
Project Title: "Physicians quick response service”
Geographic Reach: California
Funding Amount: $4,254,615
Estimated 3-Year Savings: $3,229,481
Summary: Palliative Care Consultants of Santa Barbara is receiving an award to provide health care services to the frail elderly in times of crisis. The intervention will create new options for frail elderly to access rapid assessment and treatment in their homes through a Rapid Response Team (RRT) dispatched to the homes of seniors who have fallen ill. This approach will reduce delays in care for the frail elderly and create lower exposure to hospitalization-related risks. Specially trained first responders will arrive within one hour to initiate the in-home assessment and triage process. The focus of this initiative is to provide active treatment to frail elderly patients in their home. The goal is to reduce emergency room visits and avoidable hospital admissions, increase patient satisfaction, and provide better, more immediate care through a system that is patient-centered and timely.
Over a three-year period, Palliative Care Consultants of Santa Barbara’s program will train an estimated 32 workers and create an estimated 20 jobs. New workers will include first responders, a project manager, enrollment specialists, and administrative assistants.
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.
SAN FRANCISCO COMMUNITY COLLEGE
Project Title: “Transitions clinic network: linking high-risk Medicaid patients from prison to community primary care”
Geographic Reach: Alabama, California, Connecticut, District of Columbia, Maryland, Massachusetts, New York, Puerto Rico
Funding Amount: $6,852,153
Estimated 3-Year Savings: $8,115,855
Summary: The San Francisco Community College District (City College of San Francisco), in partnership with the University of California San Francisco and Yale University, is receiving an award to address the health care needs of high-risk/high-cost Medicaid and Medicaid-eligible patients released from prison, targeting eleven community health centers in six states, The District of Columbia, and Puerto Rico. The program will work with the Department of Corrections to identify patients with chronic medical conditions prior to release and will use community health workers trained by City College of San Francisco to help these individuals navigate the care system, find primary care and other medical and social services, and coach them in chronic disease management. The outcomes will include reduced reliance on emergency room care, fewer hospital admissions, and lower cost, with improved patient health and better access to appropriate care.
Over a three-year period, the San Francisco Community College District's program will create an estimated 12.3 jobs and train an estimated 53.7 workers. The new workforce will include 7 community health workers, 11 part-time panel managers, 2 part-time project coordinators, one research analyst and two part-time project staff.
SOUTH COUNTY COMMUNITY HEALTH CENTER
Project Title: “Ravenswood Family Health Care Innovation Project"
Geographic Reach: California
Funding Amount: $7,302,463
Estimated 3-Year Savings: $6.2 million
Summary: South County Community Health Center (Ravenswood Family Health Center) in partnership with Health Plan of San Mateo, San Mateo County Health System, and Nuestra Casa, is receiving an award to create a health disparities collaborative for over 19 thousand people with diabetes in a multi-cultural, high-risk, high-cost population in southeast San Mateo County, California. This project will train a multi-cultural staff that will, in a responsive and culturally appropriate manner, support and motivate patients to follow and adhere to evidence-based care plans. These care managers will also provide assistance in overcoming barriers to obtaining services with estimated savings of over $6 million. Over the three-year period, South County Community Health Center program will train an estimated 60 health care workers and create an estimated 28.8 new jobs. These trained, multi-cultural workers will support patient-center medical teams by coordinating care for patients.
SUTTER HEALTH
Project Title: “Advanced Illness Management (AIM)"
Geographic Reach: California
Funding Amount: $13,000,000
Estimated 3-Year Savings: $29,388,894
Summary: Sutter Health is receiving an award to expand their Advanced Illness Management program (AIM) across the entire Sutter Health system in Northern California, serving patients who have severe chronic illness but are not ready for hospice care, are in clinical, functional, or nutritional decline, and are high-level consumers of health care. Such patients generally experience poorly coordinated care and lower quality of care, particularly in relationship to their personal goals, but account for a disproportionate share of Medicare. AIM addresses these issues through a complex medical home model that uses home care nurse-led interdisciplinary teams to coordinate and deliver care that encourages patient self-management of chronic illness, supports disease modifying therapies and provides symptomatic relief. The program will improve care and patient quality of life, increase physician, caregiver, and patient satisfaction, and reduce Medicare costs associated with avoidable hospital stays, emergency room visits, and days spent in intensive care units and skilled nursing facilities.
Over a three-year period, the Sutter Health’s program will train an estimated 192 workers and will create an estimated 89 jobs. The new workforce will include training care transition teams comprised of nurses, social workers, nurses, clinical pharmacist and home care aides.
THE NATIONAL HEALTH CARE FOR THE HOMELESS COUNCIL
Project Title: “Community health workers and HCH: a partnership to promote primary care”
Geographic Reach: California, Florida, Illinois, Massachusetts, Nebraska, New Hampshire, North Carolina, Texas
Funding Amount: $2,681,877
Estimated 3-Year Savings: $1.5 million
Summary: The National Health Care for the Homeless Council is joining into a cooperative agreement to serve ten communities across various regions in the U.S. to reduce the number of emergency department visits and lack of primacy care services for over 1700 homeless individuals. The intervention will integrate community health workers into Federally Qualified Health Centers to conduct outreach and case coordination for transitioning this population from the emergency department to a health center, thus reducing unnecessary emergency department visits and improving quality of care for this population with estimated savings of approximately $1.4million. Over the three-year period, National Health Care for the Homeless Council’s program will train an estimated 101 health care workers, while creating an estimated 17 new jobs. The workers will include community health workers who will conduct outreach and care coordination.
TRUSTEES OF DARTMOUTH COLLEGE
Project Title: “Engaging patients through shared decision making: using patient and family activators to meet the triple aim”
Geographic Reach: California, Colorado, Idaho, Iowa, Maine, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, New York, Oregon, Texas, Utah, Vermont, Washington
Funding Amount: $26,172,439
Estimated 3-Year Savings: $63,798,577
Summary: The Trustees of Dartmouth College is receiving an award to collaborate with 15 large health care systems around the country to hire Patient and Family Activators (PFAs). The PFAs will be trained to engage in shared decision making with patients and their families, focusing on preferences and supplying sensitive care choices. PFAs may work with patients at a single decision point or over multiple visits for those with chronic conditions. It is anticipated that this intervention will lead to a reduction in utilization and costs and provide invaluable data on patient engagement processes and effective decision making—leading to new outcomes measures for patient and family engagement in shared decision making.
Over a three-year period, the Trustees of Dartmouth College-sponsored program will train 5,775 health care workers and create 48 positions for patient and family activators.
UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
Project Title: “Cost-effective delivery of enhanced home caregiver training”
Geographic Reach: Arkansas, California, Hawaii, Texas
Funding Amount: $3,615,818
Estimated 3-Year Savings: $1,286,251
Summary: The University of Arkansas for Medical Sciences is receiving an award for enhanced training of both family caregivers and the direct-care workforce in order to improve care for elderly patients requiring long-term care services, including Medicare beneficiaries qualifying for home healthcare services and Medicaid beneficiaries who receive homemaker and personal care assistant services. Inadequate training of the direct care worker has been shown to have a direct impact on the quality of care to the elderly. By enhancing the training of the direct-care workforce, the increasingly complex care needs of the older adult can be better managed in the home, leading to fewer avoidable hospital admissions and readmissions, better preventive care, better compliance with care, and avoidance of unnecessary institutional care. The investments made by this grant are expected to generate cost savings beyond the three year grant period.
Over a three-year period, The University of Arkansas for Medical Sciences’ program will train an estimated 2100 workers and will create an estimated four jobs. The new workforce will include a project manager, a nurse educators and an administrative assistant. Additionally, this program will train home care givers in rural areas using distance education. Through tuition and textbook support this program will increase the number of certified caregivers providing direct care to elderly adults.
REGENTS OF THE UNIVERSITY OF CALIFORNIA, LOS ANGELES
Project Title: “UCLA Alzheimer’s and dementia care: comprehensive, coordinated, patient-centered”
Geographic Reach: California
Funding Amount: $3,208,540
Estimated 3-Year Savings: $6.9 million
Summary: The Regents of the University of California, Los Angeles, are receiving an award to expand a new program to provide coordinated, comprehensive, patient and family-centered, and efficient care for approximately 1000 Medicare and Medicaid beneficiaries with Alzheimer’s disease or other forms of dementia. The UCLA Health System operates in the western area of Los Angeles County. By training and deploying professional and non-professional workers and unpaid volunteers, expanding a dementia registry, conducting patient needs assessments, and creating individualized dementia care plans, the program is expected to reduce hospitalizations and shorten hospital stays, reduce emergency room visits, and improve patient health, caregiver health, and quality of care with estimated savings of approximately $6.9 million. Over the three-year period, the Regents of the University of California, Los Angeles’ program will train an estimated 2500 workers, while creating an estimated 10 new jobs. These workers will include nurse practitioners, who will be trained as dementia care managers. These dementia care managers will in turn help train primary care providers and patient care givers on dementia care.
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.
UNIVERSITY OF SOUTHERN CALIFORNIA
Project Title: "Integrating clinical pharmacy services in safety-net clinics”
Geographic Reach: California
Funding Amount: $12,007,677
Estimated 3-Year Savings: $43,716,000
Summary: The University of Southern California is receiving an award for a plan to integrate clinical pharmacy services into safety net clinics, providing medication therapy management, disease state management, medicine reconciliation, medication access services, patient counseling, drug information education, preventive care programs, provider education, and quality improvement review for care providers and for the underserved and vulnerable populations of Santa Ana, Huntington Beach, and Garden Grove. This will improve medication adherence, confirm the appropriateness and safety of medication use, and reduce avoidable hospitalizations and emergency room visits, while improving patient and population health.
Over a three-year period, The University of Southern California program will train an estimated 17 workers and will create an estimated 27 jobs. The new workforce will include a programmer, a project manager, six pharmacists, and six pharmacy residents. Additionally, this program will partner with the East Los Angeles Occupational Center technician training program to develop curricula that will expand the roles of the 11 pharmacy technicians who will be trained to perform patient navigator and data management duties in clinical pharmacy teams.