The 26 award recipients and their projects are listed on next pages:

BETH ISRAEL DEACONESS
Project Title: “Preventing avoidable re-hospitalizations: Post-Acute Care Transition Program (PACT)”
Geographic Reach: Massachusetts
Funding Amount: $4,937,191
Estimated 3-Year Savings: $12.9 million
Summary: Beth Israel Deaconess Medical Center, in Boston, is receiving an award to improve care and reduce hospital readmissions for over Medicare and beneficiaries dually eligible for Medicare and Medicaid who represent over 8000 discharges for conditions such as congestive heart failure, acute myocardial infarctions, and pneumonia. By integrating care, improving patients’ transitions between locations of care, and focusing on a battery of evidence-based best practices, this model is expected to prevent complications and reduce preventable readmissions, resulting in better quality health care at lower cost in the urban Boston area with estimated savings of almost $13 million over 3 years. Over the three-year period, Beth Israel’s program will train an estimated 11 health care workers, while creating an estimated 11 new jobs. These workers will include care transition specialists who will help integrate care between hospital and primary care practices.

CENTER FOR HEALTH CARE SERVICES
Project Title: “A recovery-oriented approach to integrated behavioral and physical health care for a high-risk population”
Geographic Reach: Texas
Funding Amount: $4,557,969
Estimated 3-Year Savings: $5 million
Summary:  The Center for Health Care Services in San Antonio, Texas, is receiving an award to integrate behavioral care and health care for a group approximately 260 homeless adults in San Antonio with severe mental illness or co-occurring mental illness and substance abuse disorders, at risk for chronic physical diseases. Their intervention will integrate health care into behavioral health clinics, using a multi-disciplinary care team to coordinate behavioral, primary, and tertiary health care for these people—most of them Medicaid beneficiaries or eligible for Medicaid—and is expected to improve their capacity to self-manage, reducing emergency room admissions, hospital admissions, and lowering cost, while improving health and quality of life and with estimated savings of $5 million over 3 years. Over the three-year period, the Center for Health Care Services’ program will train an estimated 24 health care workers and create an estimated 24 new jobs. These workers will provide peer support to generate readiness for change, build motivation, and sustain compliance.

COOPER UNIVERSITY HOSPITAL
Project Title: N/A
Geographic Reach: New Jersey
Funding Amount: $2,788,457
Estimated 3-Year Savings: $6.2 million
Summary: Cooper University Hospital, serving Camden, N.J., and adjoining areas, is receiving an award to better serve over 1200 patients with complex medical needs who have relied on emergency rooms and hospital admissions for care. The intervention will use care management and care transition teams to work with these people to reduce avoidable emergency room visits, inpatient hospital admissions, and hospital readmissions and improve their access to primary health care. This approach is expected to result in better health care outcomes and lower cost with estimated savings of approximately $6.1 million. Over the three-year period, Cooper University Hospital’s program will train an estimated 14 health care workers, while creating an estimated 14 new jobs. These workers will include non-clinical staff, like AmeriCorps volunteers and community health workers, who will serve as part of multidisciplinary teams to support care coordination activities.

COURAGE CENTER D/B/A CAMP COURAGE
Project Title:  “Courage Center”
Geographic Reach: Minnesota
Funding Amount: $1,767,667
Estimated 3-Year Savings: $2 million
Project Summary: Courage Center is receiving an award to test a community-based medical home model to serve 300 adults with disabilities and complex health conditions, particularly complex neurological conditions, in Minneapolis-St. Paul metropolitan area. The intervention will coordinate and improve access to primary and specialty care, increase adherence to care, and empower participants to better manage their own health. Over 50 Independent Living Skills Specialists, Peer Leaders, and other health professionals will be trained with enhanced skills to fulfill the medical home mission. This community-based and patient-centered approach is expected to reduce avoidable hospitalizations, lower cost, and improve the quality of care for this vulnerable group of people with an estimated savings of over $2 million over the three year award.

DELTA DENTAL PLAN OF SOUTH DAKOTA
Project Title: “Improving the care and oral health of American Indian mothers and young children and American Indian people with diabetes on South Dakota reservations”
Geographic Reach: South Dakota
Funding Amount: $3,364,528
Estimated 3-Year Savings: $6.2 million
Summary:  Delta Dental Plan, which covers more than 30,000 isolated, low-income and underserved Medicaid beneficiaries and other American Indians on reservations throughout South Dakota, is receiving an award to improve oral health and health care for American Indian mothers, their young children, and American Indian people with diabetes. Providing preventive care will help avoid and arrest oral and dental diseases, repair damage, prevent recurrence, and ultimately, reduce the need for surgical care. The project will also work with diabetic program coordinators to identify and treat people with diabetes.  By coordinating community-based oral care with other social and care provider services, the model is expected to reduce the high incidence of oral health problems in the area, improve patient access, monitoring, and overall health, and lower cost through prevention with estimated savings of over $6 million. Over the three-year period, the Delta Dental of South Dakota program will train an estimated 24 health care workers and create an estimated 24 new jobs. These workers will be comprised of registered dental hygienists and community health representatives who will treat and educate patients and coordinate their dental care.

DUKE UNIVERSITY
Project Title:  “From clinic to community: Achieving health equity in the southern United States”
Geographic Reach: North Carolina and West Virginia
Funding Amount: $9,773,499
Estimated 3-Year Savings: $20.8 million
Summary: Duke University, in conjunction with the University of Michigan National Center for Geospatial Medicine, Durham County Health Department (Durham County, N.C.), Cabarrus Health Alliance (Cabarrus County, N.C.), Mississippi Public Health Institute (Quitman County, N.C.), Marshall University, and Mingo County Health Department (Mingo County, W.V.) is receiving an award for its plan to reduce death and disability from Type 2 diabetes mellitus among fifty-seven thousand people in four Southeastern counties who are underserved and at-risk populations in the Southeast. The program will use informatics systems that stratify patients and neighborhoods by risk, target communities in need of higher-intensity interventions, and serve as the basis for decision support and real-time monitoring of interventions. Local home care teams will provide patient-centered coordinated care to improve outcomes and lower cost – expecting to reduce hospital and emergency room admissions and reduce through preventive care the need for amputations, dialysis, and cardiac procedures with estimated savings of over $20 million. Over the three-year period, this collaborative program will train an estimated 88 health care workers and create an estimated 31 new jobs. These workers include new types of health workers including information officers, health integrators, and community health workers, who will use novel technologies to facilitate communication, education, and care delivery.

EMORY UNIVERSITY (CENTER FOR CRITICAL CARE)
Project Title: “Rapid Development and Deployment of Non-Physician Providers in Critical Care”
Geographic Reach: Georgia
Funding Amount: $10,748,332
Estimated 3-Year Savings: $18.4 million
Project Summary: Emory University, in partnership with Philips Company (a Tele-Intensive Care Unit contractor) and several medical centers including Saint Joseph’s Health System, Northeast Georgia Medical Center, and Southern Regional Medical Center, is receiving an award to hire more than 40 critical care professionals, including 20 nurse practitioners (NP) and physician assistants (PA) who will be deployed to undeserved and rural hospitals in Northern Georgia. Training in the use of these tele-ICU services for supervision of those NP and PA providers as well as for support of nurses and allied health personnel will reach an additional 400 clinical, technical and administrative support professionals who form the local hospital critical care teams. This innovative strategy will serve over ten thousand Medicare and Medicaid beneficiaries and aim to mitigate problems associated with the lack of critical care doctors in the region, improve access to quality health care, and lower costs associated with inefficient care and a lack of transport services which could save approximately $18.4 million over three years.

FINITY COMMUNICATIONS, INC.
Project Title:  “EveryBODY Get Healthy”
Geographic Reach: Oregon and Pennsylvania
Funding Amount: $4,967,962
Estimated 3-Year Savings: $8.7 million
Summary: Finity Communications, Inc., is receiving an award to improve health care for high need populations in the greater Philadelphia area. The intervention will use health information technology to track and monitor over 120,000 at-risk patients, create a participant engagement program, develop integrated health profiles and care management plans, and evaluate and reassess treatment on a continuing basis. This comprehensive approach to health care is expected to reduce the total cost of care through prevention, maintaining wellness, and condition management with estimated savings of approximately $8.7 million. Over the three-year period, Finity Communications, Inc’s, program will train an estimated 13 health care workers and create an estimated 12 new jobs. These workers will support lifestyle change through prevention outreach and wellness education programs.

GEORGE WASHINGTON UNIVERSITY
Project Title: “Using Telemedicine in peritoneal dialysis to improve patient adherence and outcomes while reducing overall costs”
Geographic Reach: Maryland, Virginia, Pennsylvania, District of Columbia
Funding Amount: $1,939,127
Estimated 3-Year Savings: $1.7 million
Summary: George Washington University is receiving an award to improve care for about 300 patients on peritoneal dialysis in Washington, D.C., and eventually in Philadelphia and Southern Maryland. The intervention will use telemedicine to offer real-time, continuous, and interactive health monitoring to improve patient safety and treatment. The model will train a dialysis nurse workforce in prevention, care coordination, team-based care, telemedicine, and the use of remote patient data to guide treatment for co-morbid, complex patients. This approach is expected to improve patient access to care, adherence to treatment, self-management, and health outcomes, reducing cost of care for peritoneal dialysis patients with complex health care needs by reducing overall hospitalization days with estimated savings of approximately $1.7 million. Over the three-year period, George Washington University’s program will train an estimated three health care workers and create an estimated three new jobs. These workers will provide clinical support and health monitoring via the web to home dialysis patients.