Health Care Innovation Awards: Iowa
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.
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, 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.
SANFORD HEALTH
Project Title: "Sanford One Care: transforming primary care for the 21st Century”
Geographic Reach: Iowa, Minnesota, North Dakota, South Dakota
Funding Amount: $12,142,606
Estimated 3-Year Savings: $14,135,429
Summary: Sanford Health is receiving an award to transform health care delivery through the full integration of primary and behavioral health care in South Dakota, North Dakota and Minnesota clinics. Sanford's enhanced fully integrated medical home model features patient‐centered collaborative teams of primary and behavioral health professionals. The Medicare, Medicaid and CHIP beneficiaries along with the Native American and multicultural populations will benefit significantly from this award. This model of workforce development and rapid process redesign, along with the integration of behavioral health and primary care, will improve clinical outcomes and drive efficient utilization of resources.
Key aims include transforming the role of Primary Care, integrating RN Health Coaches and Behavioral Health Triage Therapists, fully integrating behavioral health care into the medical home model, maximizing Information Technology and standardizing transparent clinical metrics. Tele-health technology will allow patients at remote clinic sites to access enhanced clinical services including psychologists and psychiatrists. Over a three-year period, Sanford Health’s program will train an estimated 425 health care providers creating enhanced clinical and patient engagement skills, as well as create an estimated 23 jobs in the areas of clinical services, behavioral health, and information technology.
UNIVERSITY OF IOWA
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
Summary: The University of Iowa, in partnership with the 11 hospitals comprising its Critical Access Hospital Network, is receiving an award to improve care coordination and communication with practitioners in ten rural Iowa counties. The program will serve Medicare, Medicaid, and Medicare/Medicaid dual-eligible beneficiaries and privately insured and uninsured patients who have complex illness, including psychiatric disorders, heart disease, kidney disease, cancer, endocrine and gastrointestinal disorders, and geriatric issues. The program will coordinate care through teams comprised of nurses, social workers, and pharmacists along with specialty physicians (including psychiatrists) using telehealth and web-based personal health records. The program is based on the University of Iowa's significant past experience in 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 eleven community 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.
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 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.