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.
DENVER HEALTH AND HOSPITAL AUTHORITY
Project Title: “Integrated model of individualized ambulatory care for low income children and adults”
Geographic Reach: Colorado
Funding Amount: $19,789,999
Estimated 3-Year Savings: $12,792,256
Summary: Denver Health and Hospital Authority is receiving an award to create an ambulatory care model that will provide individualized care for patients' medical, behavioral and social needs. This model will target low income children and adults with diverse health care needs. It will coordinate care and offer self-care support between visits, enabled by HIT and team-based patient navigators, and will integrate physical and behavioral health services in existing primary care settings and newly created high risk clinics. The program will reduce reliance on emergency room care and reduce avoidable hospitalizations by providing better access to outpatient and social services, better care management and self-management of care, and better coordination and utilization of existing services, as well as more individualized care for the patients' medical, behavioral and social needs. The investments made by this grant are expected to generate cost savings beyond the three year grant period.
Over a three-year period, Denver Health and Hospital Authority will hire and train 25 patient navigators and fill 20 new health information technology positions.
FEINSTEIN INSTITUTE FOR MEDICAL RESEARCH
Project Title: "Using care managers and technology to improve the care of patients with schizophrenia”
Geographic Reach: Colorado, Florida, Michigan, Minnesota, Missouri, New Hampshire, New Mexico, New York, Oregon
Funding Amount: $9,380,855
Estimated 3- Year Savings: $10,080,000
Summary: The Feinstein Institute for Medical Research is receiving an award to develop a workforce that is capable of delivering effective treatments, using newly available technologies, to at-risk, high-cost patients with schizophrenia. The intervention will test the use of care managers, physicians, and nurse practitioners trained to use new technology as part of the treatment regime for patients recently discharged from the hospital at community treatment centers in nine states. These trained providers will educate patients and their caregivers about pharmacologic management, cognitive behavior therapy, and web-based/home-based monitoring tools for their conditions. This intervention is expected to improve patients’ quality of life and lower cost by reducing hospitalizations.
Over a three-year period, the Feinstein Institute for Medical Research will retrain nurse practitioners, physician assistants, physicians, and case managers to use newly available mental health protocols and health technology resources.
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.
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.
SOUTHEAST MENTAL HEALTH SERVICES
Project Title: "TIPPING POINT: Total Integration, Patient Navigation and Provider Training Project for Powers County, Colorado"
Geographic Reach: Colorado
Funding Amount: $1,405,924
Estimated 3-Year Savings: $1,875,000
Summary: Southeast Mental Health Services is receiving an award to coordinate comprehensive, community-based care for high-risk, high-cost, and chronically ill residents of rural Prowers County, Colorado. The program will employ trained patient navigators to increase patients' access to primary and behavioral care, preventive care, and early intervention services, offering team-based education and coaching to improve both population health and self-management of disease. The results will include a reduction in emergency room visits and other high cost interventions, mitigation of the progress of chronic disease, better health habits, and better care and quality of life for these vulnerable patients. Southeast Mental Health Services will contract with Otero Junior College to develop a magnet “Health Navigator” training program to serve current and future healthcare workers across rural Colorado. Over a three-year period, Southeast Mental Health Service's program will train an estimated 62 workers and create an estimated 8.25 FTE jobs. The new workers will include health navigators, instructors, a marketing/communications assistant, and a project manager.
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.
UPPER SAN JUAN HEALTH SERVICE DISTRICT
Project Title: "Southwest Colorado cardiac and stroke care”
Geographic Reach: Colorado
Funding Amount: $1,724,581
Estimated 3-Year Savings: $8.1 million
Summary: The Upper San Juan Health Service District is receiving an award to expand access to specialists and improve the quality of acute care in rural and remote areas of southwestern Colorado. Their care delivery model will offer cardiovascular early detection and wellness programs, implement a telemedicine acute stroke care program, use telemedicine and remote diagnostics for cardiologist consultations, and upgrade and retrain its Emergency Medical Services Division (EMS) to manage urgent care transports and in-home follow-up patient care for over 3400 patients in medically underserved areas in Southwest Colorado. The program will provide access to cardiologists and neurologists and is expected to reduce cardiovascular risk, improve patient outcomes, create healthier communities, and reduce health care costs with estimated savings of approximately $8.1 million. Over the three-year period, the Upper San Juan Health Service District’s program will train an estimated 25 paramedics and telehealth clinicians and create 13 new jobs. These workers will provide a new type of clinical team that will improve care outcomes for rural cardiovascular patients.
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