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.
ALTARUM INSTITUTE
Project Title: “Comprehensive community-based approach to reducing inappropriate imaging”
Geographic Reach: Michigan
Funding Amount: $8,366,178
Estimated 3-Year Savings: $33,237,555
Summary: Altarum Institute, in partnership with United Physicians (IPA) and Detroit Medical Center Physician Hospital Organization, is receiving an award to reduce unnecessary imaging studies for beneficiaries in Southeastern Michigan. This multifaceted intervention will establish a data-exchange system between primary care and imaging facilities to increase evidence-based decision-making among physicians ordering MRIs and CTs in the lumbar-spine, cervical-spine, lower extremities, shoulder, head, chest and abdomen. The goal is to reduce CT volume by 17.4 percent and MRI volume by 13.4 percent over three years, resulting in a 17 percent reduction in imaging costs without any loss in diagnostic accuracy or restrictions on the ordering of tests.
Over a three-year period, Altarum Institute will train a network of area care providers in the use of the program’s systems and technology, while creating an estimated 23 jobs for practice consultants, health information analysts, lean practice redesign specialists, and health education specialists.
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, Missouri, Minnesota, 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.
HENRY FORD HEALTH SYSTEM
Project Title: “Mobility: the 6th vital sign”
Geographic Reach: Michigan
Funding Amount: $3,773,539
Estimated 3-Year Savings: $8,837,501
Summary: The Henry Ford Health System of Detroit, Michigan is receiving an award for an innovative care model that will encourage and support patient mobility during acute inpatient hospitalizations. Their intervention addresses the hazards of immobility during hospitalization, including dehydration, malnutrition, delirium, sensory deprivation, isolation, shearing forces on skin, pressure ulcers, and respiratory complications. Henry Ford Health System expects to reduce hospital-acquired pressure ulcers and ventilator-associated pneumonia, improve quality of care and patient experience of care, and decrease length of stay in the hospital.
Over a three-year period, the Henry Ford Health System will train approximately 21 health care providers, including physical therapists and wound and ostomy-certified nurses.
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.
MICHIGAN PUBLIC HEALTH INSTITUTE
Project Title: “Michigan pathways to better health”
Geographic Reach: Michigan
Funding Amount: $14,145,784
Estimated 3-Year Savings: $17,498,641
Summary: The Michigan Public Health Institute, partnering with the Michigan Department of Community Health and the Community Health Access Project, is receiving an award to integrate community health workers (CHWs) into primary care teams in the county of Ingham and cities of Saginaw and Muskegon. These CHWs will coach patients on self-management of conditions and encourage regular primary care visits. In addition, the program will connect at-risk populations with local care and support services that address social determinants of health that impede achievement of positive health outcomes. This “Pathways Community Hub” model will decrease hospitalizations and emergency department visits by improving adherence to therapy, improving access to primary care and increasing use of preventive care and support services.
Over a three-year period, the Michigan Public Health Institute will train over 231 people and hire 87 people to serve as community health workers, providing care self-management coaching, care navigation services, and care coordination services.
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.
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, Iowa, Illinois, Indiana, Kansas, Kentucky, Louisiana, Michigan, Nevada, Massachusetts, Minnesota, Mississippi, Missouri, 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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