HEALTH RESOURCES IN ACTION
Project Title: “New England asthma innovations collaborative”
Geographic Reach: Massachusetts, Rhode Island, Connecticut, Vermont
Funding Amount: $4,040,657
Estimated 3-Year Savings: $4.1 million
Summary: Health Resources in Action is receiving an award for a program of its New England Asthma Regional Council, titled the New England Asthma Innovations Collaborative (NEAIC). NEIAC is a multi-state, multi-sector partnership that includes health care providers, payers, and policy makers aimed at creating an innovative Asthma Marketplace in New England that will increase the supply and demand for high-quality, cost-effective health care services. Over the three year funding period, services will be delivered to over 1400 children ages 2-17 with persistent asthma who have had at least one related emergency department visit, observation stay, hospitalization or received a prescription in the 12 months prior to enrollment. The intervention will lower costs of asthma care by delivering cost-effective prevention oriented care in clinics and at home to reduce preventable pediatric-related emergency department visits and hospital admissions with estimated savings of over $4 million. NEAIC will also train an estimated 64 health care workers, while creating an estimated 17 new jobs. These workers will include well-trained community health workers and asthma educators. Finally, NEAIC will work to sustain these cost-effective services by piloting reimbursement methodologies with payers. In sum, NEAIC will create a new type of workforce and service delivery model that targets cost-effective and culturally competent care, which features patient self-management education, environmental interventions and long-term sustainability payment mechanisms of these services.

JOSLIN DIABETES CENTER, INC.
Project Title: “Pathways to better health through a new health care workforce and community”
Geographic Reach: New Mexico, Pennsylvania, District of Columbia
Funding Amount: $4,967,276
Estimated 3-Year Savings: $7.4 million
Summary: Joslin Diabetes Center, Inc., is receiving an award to expand a successful program for diabetes education, field testing, and risk assessment. Their “On the Road” program will send trained community health workers into community settings to help approximately 3000 Medicare and Medicaid beneficiaries and low income/uninsured populations understand their risks and improve health habits for the prevention and management of diabetes. The program will target at risk and underserved populations in New Mexico, Pennsylvania, and Washington, D.C., helping to prevent the development and progression of diabetes and reducing overall costs, avoidable hospitalizations, and the development of chronic co-morbidities with estimated savings of approximately $7.4 million. Over the three-year period, Joslin Diabetes Center’s program will train an estimated 27 workers, while creating an estimated 9 new jobs. These workers will include community health workers and health education instructors who will educate patients in managing diabetes and pre-diabetes.  

KITSAP MENTAL HEALTH SERVICES
Project Title: “Race to health: coordination, integration, and innovations in care”
Geographic Reach: Washington
Funding Amount: $1,858,437
Estimated 3-Year Savings: $5.8 million
Summary:  Kitsap Mental Health Services of Kitsap County, Wash., is receiving an award to integrate care for one thousand severely mentally ill or severely emotionally disturbed adults and children, many of them Medicare, Medicaid, and/or CHIP beneficiaries, with at least one co-morbidity.   Research shows that health care for the severely mentally ill /severely emotionally disturbed population is often fragmented, ineffective, and inefficient, resulting in poor health and premature death.  By providing integrated behavioral health management and preventive care through primary care physicians, other care providers, and social service organizations, the project is expected to improve beneficiary health and reduce avoidable emergency room visits and hospitalizations with estimated savings of approximately $5.8 million. Over the three-year period, Kitsap Mental Health Services’ program will train an estimated 130 health care workers, while generating an estimated 12.5 new jobs, creating a transformed health care workforce cross-trained in behavioral and physical health disciplines.

LIFELONG MEDICAL CARE
Project Title: “Health Care Innovation Challenge: LifeLong complex care initiative to achieve the Triple Aim”
Geographic Reach: California
Funding Amount: $1,109,231
Estimated 3-Year Savings: $1.1 million
Summary: LifeLong Medical Care is receiving an award to further integrate care and encourage healthy behavior, and reduce excessive emergency room and hospital visits among the disabled among 9750 disabled, homeless, and mentally ill Medicaid and beneficiaries dually eligible for Medicare and Medicaid to reduce excessive emergency room and hospital visits. The intervention will train disabled Medicaid and dually eligible beneficiaries to teach healthy behaviors to their peers and encourage self management, with the support of a team of nurse care managers. Improved care and better health for these to these high risk patients will lower costs with estimated savings of approximately $1 million. Over the three-year period, LifeLong Medical Care’s program will train an estimated 60 health care workers, while creating an estimated 60 new jobs. These workers will include peer health coaches and nurse care managers who will facilitate integrated care for seniors and for low-income adults with disabilities.

MOUNTAIN AREA HEALTH EDUCATION CENTER
Project Title: “Regional integrated multi-disciplinary approach to prevent and treat chronic pain in North Carolina”
Geographic Reach: North Carolina
Funding Amount: $1,186,045
Estimated 3-Year Savings: $2.4 million
Summary: The Mountain Area Health Education Center, serving 16 counties in Western North Carolina, is receiving an award to test team-based enhanced primary care for patients with chronic pain, whose treatment can be both costly and avoidably frequent. The target population for the test includes over 2,000 patients. The intervention will create multidisciplinary teams to provide enhanced primary care, using mid-level providers to co-manage care and providing counseling and medication management services. The result is expected to be better pain control, improved health, a reduction in the frequency of outpatient visits, and additional cost reductions arising from the use of mid-level providers with estimated savings of approximately $2.4 million. Over the three-year period, Mountain Area Health Education Center's program will train an estimated 390 health care workers and create an estimated 7.5 new jobs. These health workers will form multidisciplinary teams to provide enhanced primary care to patients with chronic pain in rural North Carolina.

THE NATIONAL HEALTH CARE FOR THE HOMELESS COUNCIL
Project Title: “Community health workers and HCH:  a partnership to promote primary care”
Geographic Reach: New Hampshire, Texas, Nebraska, Massachusetts, Illinois, Florida, North Carolina, California
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 healthcare workers, while creating an estimated 17 new jobs. The workers will include community health workers who will conduct outreach and care coordination.

OCHSNER CLINIC FOUNDATION
Project Title: “Comprehensive stroke care model through the continuum of care”
Geographic Reach: Louisiana
Funding Amount: $3,867,944
Estimated 3-Year Savings: $4.9 million
Summary: Ochsner Clinic Foundation is receiving an award to better serve almost 1000 acute care stroke patients in Jefferson and St. Tammany parishes in Louisiana. The model will employ a stroke management and quality assurance through a telemedicine system called “Stroke Central.” This system will enable care providers to monitor patients, evaluate outcomes, and check on medication and treatment adherence on a real time basis. This process will allow care providers to give telemedical “check-ups” to their patients, improving acute stroke management, improving patients’ quality of life, and lowering cost by reducing complications from urinary tract infections and pneumonia, preventing readmissions, and replacing outpatient visits with estimated savings of almost $5 million. Over the three-year period, Ochsner Clinic Foundation’s program will train an estimated 38.2 health care workers and create an estimated 12 new jobs. These workers will provide tele-consultation, assessment, and monitoring support for stroke care.

PITTSBURGH REGIONAL HEALTH INITIATIVE
Project Title: Creating a Virtual Accountable Care Network for Complex Medicare Patients
Geographic Reach: Pennsylvania
Funding Amount: $10,419,511
Estimated 3-Year Savings: $74.1 million
Summary: Pittsburgh Regional Health Initiative is receiving an award for a plan to create specialized support centers, staffed by nurse care managers and pharmacists, to help small primary care practices offer more integrated care within the service areas of seven regional hospitals in Western Pennsylvania. The project will focus not only on approximately 25,000 Medicare beneficiaries with COPD, CHF, and CAD, but also the general primary care population of this area. The resulting teams will provide support for care transitions, intensive chronic disease management, medication adherence, and other problems associated with a lack of communication in health care systems at large and the resulting fragmentation of health care for patients. This approach is expected to reduce 30-day readmissions and avoidable disease-specific admissions with estimated savings of approximately $74 million.  Over the three-year period, Pittsburgh Regional Health Initiative’s program will train an estimated 450 health care workers and create an estimated 26 new jobs. These workers will combine core competencies in the management of specific diseases with primary care support skills, and will be trained in evidence-based pathways of care.

REGENTS OF THE UNIVERSITY OF CALIFORNIA, LOS ANGELES
Project Title: “UCLA Alzheimer’s and dementia care:  comprehensive, coordinated, patient-centered”
Geographic Reach: California
Funding Amount: $3,208,540
Estimated 3-Year Savings: $6.9 million
Summary: The Regents of the University of California, Los Angeles, are receiving an award to expand a new program to provide coordinated, comprehensive, patient and family-centered, and efficient care for approximately 1000 Medicare and Medicaid beneficiaries with Alzheimer’s disease or other forms of dementia. The UCLA Health System operates in the western area of Los Angeles County. By training and deploying professional and non-professional workers and unpaid volunteers, expanding a dementia registry, conducting patient needs assessments, and creating individualized dementia care plans, the program is expected to reduce hospitalizations and shorten hospital stays, reduce emergency room visits, and improve patient health, caregiver health, and quality of care with estimated savings of approximately $6.9 million. Over the three-year period, the Regents of the University of California, Los Angeles’ program will train an estimated 2500 workers, while creating an estimated 10 new jobs. These workers will include nurse practitioners, who will be trained as dementia care managers. These dementia care managers will in turn help train primary care providers and patient care givers on dementia care.