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Health Care Innovation Awards: New York

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.

BRONX REGIONAL HEALTH INFORMATION ORGANIZATION (BRONX RHIO)

Project Title: “The Bronx Regional Informatics Center (BRIC)”
Geographic Reach: New York
Funding Amount: $12,839,157
Estimated 3-Year Savings: $15,419,460

Summary: The Bronx Regional Health Information Organization (Bronx RHIO), in partnership with its member organizations and Bronx Community College, Weill Cornell Medical College, and the Emergency Health Information Technology group at Montefiore Medical Center, is receiving an award to create the Bronx Regional Informatics Center, which will develop data registries and predictive systems that will proactively encourage early care interventions and enable providers to better manage care for high-risk, high-cost patients. The project will improve patient outcomes, improve overall health for Bronx residents, reduce the cost of care for Medicare and Medicaid by over $15 million, and train health care workers to coordinate these quality improvement efforts.

Over a three-year period, The Bronx RHIO will create an estimated 30 jobs, including positions for intervention team members and community health advocates.

DEVELOPMENTAL DISABILITIES HEALTH SERVICES

Project Title: “Expanding and testing a Nurse Practitioner-led health home model for individuals with developmental disabilities”
Geographic Reach: Arkansas, New Jersey, New York
Funding Amount: $3,701,528
Estimated 3-Year Savings: $5,374,080

Summary: Developmental Disabilities Health Services is receiving an award to test a developmental disabilities health home model, using care management/primary care teams of nurse practitioners and MDs to improve the health and care of persons with developmental disabilities in important clinical areas. The health homes will serve individuals with intellectual and developmental disabilities who receive Medicaid and/or Medicare benefits in New Jersey, the Bronx, and Little Rock, Arkansas, and are eligible for services in each state's Home and Community-Based Services waiver program, as well as individuals who are commercially insured and uninsured. All of these patients are considered high-risk and many have co-morbidities. By integrating care using nurse practitioners as care coordinators and health care providers, the health homes will improve primary care, mental health care, basic neurological care, and seizure management for these beneficiaries, resulting in reduced emergency room visits and lower out-of-home placement and institutionalization.

Over a three-year period, Developmental Disabilities Health Services will retrain and deploy 20 individuals to provide and coordinate primary care and mental health services in health homes for persons with developmental disabilities.

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.

FINGER LAKES HEALTH SYSTEM AGENCY

Project Title: “Transforming primary care delivery: a community partnership”
Geographic Reach: New York
Funding Amount: $26,583,892
Estimated 3-Year Savings: $48,021,083

Summary: Finger Lakes Health System Agency is receiving an award for a community-wide outcomes-based payment model for primary care that will serve Medicare and Medicaid beneficiaries in six counties in the Rochester, New York area. The project creates a collaborative of providers, payers, employers, government, patients, social coalitions, and community service organizations to integrate community services with primary care and leverage social and health care resources. Primary care physicians will receive technical, process, and adaptive support, and will be connected with a team of care managers, care coordinators, and community health workers. This approach will strengthen primary care and reduce avoidable hospitalizations, readmissions, and emergency room use.

Over a three-year period, the Finger Lakes Health Systems Agency will train 726 health workers and hire 76 health care providers in positions as care managers, community health workers, community-based care coordinators, and practice improvement advisors.

FUND FOR PUBLIC HEALTH IN NEW YORK

Project Title: "Parachute NYC: an alternative approach to mental health treatment and crisis services"
Geographic Reach: New York
Funding Amount: $17,608,085
Estimated 3-Year Savings: $51,696,138

Summary: The Fund for Public Health in New York, Inc., in partnership with the New York City Department of Health and Mental Hygiene’s Division of Mental Hygiene, is receiving an award to implement Parachute NYC, providing need-adapted treatment model (NATM) interventions for Medicaid beneficiaries and other people with serious mental illness who have a diagnosis of psychosis. Persons with psychosis are likely to rely on crisis-based care and generally lack adequate preventive care.Serving Manhattan, Brooklyn, Bronx, and Queens, the program will use peer health navigators, nurse practitioners, mobile crisis teams, and crisis respite centers to provide early engagement, continuity of care and combined peer and professional community service thus shifting the focus of care from crisis intervention to long-term, community-integrated treatment with access to primary care, improving crisis management and reducing emergency room visits and hospital admissions.

Over a three-year period, the Fund for Public Health in New York and the New York City Department of Health and Mental Hygiene’s Division of Mental Hygiene will train 3,800 health care providers and hire approximately 110 new behavioral health workers.

MAIMONIDES MEDICAL CENTER

Project Title: “Brooklyn Care Coordination Consortium”
Geographic Reach: New York
Funding Amount: $14,842,826
Estimated 3-Year Savings: $41,759,040

Summary: The Maimonides Medical Center of Brooklyn, New York, in partnership with a broad array of consortium members, including medical, mental health, and social service organizations, insurers, and a labor union, is receiving an award to improve care for adults with serious mental illness who live in southwest Brooklyn. The consortium will use a virtual model of care to inform the coordination of health care and services, enabling medical and mental health providers to communicate with each other and monitor patients through advanced health information technology tools. Maimonides expects this approach to reduce psychiatric and medical hospital admissions by 30 percent and reduce the total cost of care for the population.

Over a three-year period, Maimonides Medical Center will create an estimated 162 jobs, including numerous care management roles and IT implementation roles.

MAYO CLINIC

Project Title: “Patient-centric electronic environment for improving acute care performance”
Geographic Reach: Massachusetts, Minnesota, New York, Oklahoma
Funding Amount: $16,035,264
Estimated 3-Year Savings: $81,345,987

Summary: The Mayo Clinic, in collaboration with US Critical Illness and Injury Trials Group and Philips Research North America, is receiving an award to improve critical care performance for Medicare/Medicaid beneficiaries in intensive care units (ICUs). Data shows that 27% of such Medicare beneficiaries face preventable treatment errors due to information overload among ICU providers. The Mayo Clinic model will enhance effective use of data using a Cloud-based system that combines a centralized data repository with electronic surveillance and quality measurement of care responses. As a result, Mayo expects to reduce ICU complications and costs.

Over a three-year period, the Mayo Clinic will train 1440 existing ICU caregivers in four diverse hospital systems to use new health information technologies effectively in managing ICU patient care.

MOUNT SINAI SCHOOL OF MEDICINE

Project Title: "Geriatric emergency department innovations in care through workforce, informatics, and structural enhancements (GEDI WISE)"
Geographic Reach: Illinois, New Jersey, New York
Funding Amount: $12,728,753
Estimated 3-Year Savings: $40,124,805

Summary: Mount Sinai School of Medicine is receiving an award to integrate geriatric care with emergency department (ED) care in three large, urban acute care hospitals in New York, New Jersey, and Illinois. Emergency room use by older adults has doubled in the past decade and is expected to continue to increase. The Mount Sinai care model will use evidence-based geriatric clinical protocols, informatics support for patient monitoring and clinical decision support, and structural enhancements to improve patient safety and satisfaction while decreasing hospitalizations, return ED visits, unnecessary diagnostic and therapeutic services, medication errors, and adverse events, such as falls and avoidable complications.

Over a three-year period, Mount Sinai School of Medicine's GEDI WISE program will train more than 400 current health care workers and create 22 new jobs. The new hires will include nurses, nurse practitioners, physician assistants, pharmacists, physical therapy, project coordinators, research assistants, data analysts and geriatric transitional care managers.

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.

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.

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 EMERGENCY MEDICAL SERVICES

Project Title: “Better health through social and health care linkages beyond the emergency department”
Geographic Reach: New York
Funding Amount: $2,570,749
Estimated 3-Year Savings: $6.1 million

Summary: University Emergency Medical Services, a practice plan affiliated with the Department of Emergency Medicine at the University at Buffalo is receiving an award to deploy community health workers in emergency departments (EDs) to identify high-risk patients and link them to primary care, social and health services, education, and health coaching. The program targets 2300 Medicare and Medicaid beneficiaries who have had two or more emergency department visits over 12 months at two ERs in urban Buffalo, New York. These patients account for 29% of all ED patients; and, 85% and 54% of all hospital inpatients are admitted through each hospital’s emergency department. Health coaching and improved access to primary care is expected to result in lower ER utilization, reduced hospital admissions, and improved health with estimated savings of approximately $6.1 million.

Over the three-year period, University Emergency Medical Service's program will train an estimated 13 health care workers and create an estimated 13 new jobs. These community health workers will identify high-risk patients and link them to primary care, social and health services, education, and coaching.

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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