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.
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.
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.
NATIONAL COUNCIL OF YOUNG MEN'S CHRISTIAN ASSOCIATIONS OF THE UNITED STATES OF AMERICA (YMCA OF THE USA)
Project Title: "Delivery on the promise of diabetes prevention programs"
Geographic Reach: Arizona, Delaware, Florida, Indiana, Minnesota, New York, Ohio, Texas
Funding Amount: $11,885,134
Estimated 3-Year Savings: $4,273,807
Summary: The National Council of Young Men's Christian Associations of the United States of America (Y-USA), in partnership with 17 local Ys currently delivering the YMCA’s Diabetes Prevention Program, the Diabetes Prevention and Control Alliance, and 7 other leading national non-profit organizations focused on health and medicine, is receiving an award to serve 10,000 pre-diabetic Medicare beneficiaries in 17 communities across the U.S. The intervention will focus on community-based diabetes prevention through a national diabetes prevention lifestyle change program, coordinated and taught by trained YMCA Lifestyle Coaches. The goal is to prevent the progression of pre-diabetes to diabetes, which will improve health and decrease costs associated with complications of diabetes, hypercholesterolemia, and hypertension. The investments made by this grant are expected to generate cost savings beyond the three year grant period.
Over a three-year period, Y-USA and its partners will train an estimated 1500 workers and create an estimated eight jobs. The new jobs will include communication specialists, a program manager, an administrative manager, a workforce development manager, evaluation specialists, training specialists, and administrative coordinators.
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.
TransforMED
Project Title: "Multi-community partnership between TransforMED, hospitals in the VHA system and a technology/data analytics company to support transformation to PCMH of practices connected with the hospitals and development of “Medical Neighborhood”
Geographic Reach: Alabama, Connecticut, Florida, Georgia, Illinois, Indiana, Kansas, Kentucky, Massachusetts, Michigan, Mississippi, Nebraska, Oklahoma, West Virginia, Wisconsin
Funding Amount: $20,750,000
Estimated 3-Year Savings: $52,824,000
Summary: TransforMED, in partnership with 12 VHA-affiliated hospitals throughout the county, is receiving an award for a primary care redesign project to support care coordination among Patient-Centered Medical Homes (PCMH), specialty practices, and hospitals, creating “medical neighborhoods.” The project will use a sophisticated analytics engine to identify high risk patients and coordinate care across the medical neighborhood while driving PCMH transformation in a number of primary care practices in each community. Truly comprehensive care will improve care transitions and reduce unnecessary testing, leading to lower costs with better outcomes.
Over a three-year period, TransforMED’s program will train an estimated 3,024 workers and create an estimated 22 jobs. The new workers will include an innovation project manager, project control specialists, project managers, an implementation team, a project team, an integration architect, an application trainer, and a population health management advisor.
UNIVERSITY OF ALABAMA AT BIRMINGHAM
Project Title: "Deep South Cancer Navigation Network (DSCNN)"
Geographic Reach: Alabama, Florida, Georgia, Mississippi, Tennessee
Funding Amount: $15,007,263
Estimated 3-Year Savings: $49,815,239
Summary: The University of Alabama at Birmingham (UAB) and the UAB Comprehensive Cancer Center are receiving an award extending a regional network of lay health workers to expand comprehensive cancer care support services through a five state region. Working through the participating UAB Cancer Care Network affiliate sites, these patient navigation teams will improve adherence to care plans and educate cancer survivors on healthy behaviors. The intervention is designed to serve Medicare and Medicaid beneficiaries with complex or advanced disease and those with psycho-social barriers to appropriate care, many living in medically underserved inner city and rural communities. Each navigation team will include an RN site manager, health system navigators, community navigators, and a community educator. It is expected that the intervention will result in better adherence to evidence based care plans, reduced reliance on hospitals and emergency rooms for care, earlier acceptance of palliative and hospice services, and a better overall quality of life for cancer survivors.
Over a three-year period, UAB's program will train an estimated 150 lay health workers and create an estimated 56 new jobs. The new workforce will include community navigators, system navigators, data entry assistants, administrative assistants, community coordinators, Registered Nurse site managers, training managers, an evaluation and reporting manager, a communications and public relations manager, and an administrative director.
UNIVERSITY OF MIAMI
Project Title: "Expanded activities of school health initiative”
Geographic Reach: Florida
Funding Amount: $4,097,198
Estimated 3-Year Savings: $5,620,017
Summary: The University of Miami, in partnership with Medicaid health plans, the University of Florida College of Dentistry, the Miami Dade Area Education Center, the Center for Haitian Studies, the Larkin Residency program, and Overtown Youth Center, is receiving an award to improve care and access to care for children in four communities in the Miami-Dade County area who have health problems that include asthma, obesity, type II diabetes, and STDs. This intervention will expand the services and utility of school-based health clinics, increase collaboration with other care providers, services, and school-health stakeholders, and enhance use and sharing of health information technology. A team-based approach will be used to improve care and expand services, employing community health workers, nursing assistants, and dental hygienists and taking advantage of telehealth opportunities. The program will lower cost through preventive and more appropriate care and increase access to care, services, and benefits.
Over a three-year period, the University of Miami’s program will train an estimated 60 workers and will create an estimated 25 jobs. The new workforce will include community health workers, dental hygienists, physicians and nurse practitioners.
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.
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