SOUTH COUNTY COMMUNITY HEALTH CENTER
Project Title: "Ravenswood Family Health Care Innovation Project"
Geographic Reach: California
Funding Amount: $7,302,463
Estimated 3-Year Savings: $6.2 million
Summary: South County Community Health Center (Ravenswood Family Health Center) in partnership with Health Plan of San Mateo, San Mateo County Health System, and Nuestra Casa, is receiving an award to create a health disparities collaborative for over 19 thousand people with diabetes in a multi-cultural, high-risk, high-cost population in southeast San Mateo County, Calif. This project will train a multi-cultural staff that will, in a responsive and culturally appropriate manner, support and motivate patients to follow and adhere to evidence-based care plans. These care managers will also provide assistance in overcoming barriers to obtaining services with estimated savings of over $6 million. Over the three-year period, South County Community Health Center program will train an estimated 60 health care workers and create an estimated 28.8 new jobs. These trained, multi-cultural workers will support patient-center medical teams by coordinating care for patients.

UNIVERSITY OF CHICAGO
Project Title: “CommunityRx system:  linking patients and community-based service”
Geographic Reach: Illinois
Funding Amount: $5,862,027
Estimated 3-Year Savings: $6.4 million
Summary: The University of Chicago Urban Health Initiative in partnership with Chicago Health Information Technology Regional Extension Center (CHITREC) and the Alliance of Chicago Community Health Services is receiving an award to develop the CommunityRx system, a continuously updated electronic database of community health resources that will be linked to the Electronic Health Records of local safety net providers.  In real time, the system will process patient data and print out a “Health.eRx” for the patient, including referrals to community resources relevant to the patient’s condition and status. Aggregated data on patient diagnoses and referrals will be used to generate CommunityRx reports for community-based service providers to use to inform programming. The program will serve over two hundred thousand beneficiaries on the South Side of Chicago most of whom are Medicare, Medicaid and CHIP patients. The CommunityRx system will train and create new jobs for an estimated 90 individuals from this high-poverty, diverse community. This includes high school youth who will to collect data on community health resources as part of the Urban Health Initiative’s MAPSCorps program.  It will also include the creation of a new type of health worker, Community Health Information Experts (CHIEfs), who will assist patients in using the Health.eRx and engage community-based service providers in meaningful use of the CommunityRx reports. The CommunityRx builds on infrastructure supported by ARRA funding from the National Institute on Aging. Anticipated outcomes include better population health, better use of appropriate services, increased compliance with care, and fewer avoidable visits to the emergency room with estimated savings of approximately $6.4 million.

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 HOSPITALS OF CLEVELAND  
Project Title: “Transforming pediatric ambulatory care:  the physician extension team”
Organizations: University Hospitals  (UH) Rainbow Babies and Children’s Hospital at UH Case Medical Center partnering with Ohio Medicaid, CareSource, WellCare, 4 community mental health agencies, Cuyahoga Community College, Cleveland Schools, Head Start, InstantCare, and HealthSpot.  
Geographic Reach: Ohio
Funding Amount: $12,774,935
Estimated 3-Year Savings: $13.5 million
Project Summary: University Hospitals (UH) Rainbow Babies and Children’s Hospital at UH Case Medical Center is receiving an award to improve care for approximately 65,000 children with Medicaid with high rates of emergency room (ER) visits, complex chronic conditions, and  significant behavioral health problems in several counties across northeastern Ohio. The intervention will offer health care advice, referrals, and care coordination services through telehealth and home nurse hotlines; provide practice-tailored facilitation for primary care providers; and provide financial incentives to primary care physicians who reach quality performance targets, agree to offer extended hours, and make themselves available to treat these vulnerable children. Over 50 nurses, care coordinators and other health professionals will be hired and/or retrained to implement the model. The result should be better health care, with fewer avoidable ER visits, hospitalizations and lower cost – with an expected savings of more than $13 million over three years.

UNIVERSITY OF NEW MEXICO HEALTH SCIENCES CENTER
Project Title: “Leverage innovative care delivery and coordination model:  Project ECHO”
Geographic Reach: New Mexico and Washington
Funding Amount: $8,473,809
Estimated 3-Year Savings: $11.1 million
Summary: The University of New Mexico Health Sciences Center is receiving an award for its ECHO Project, which will serve areas of New Mexico and Washington. The program is base on eight years of success in New Mexico and two years in Washington State. The intervention will identify 5000 high cost, high-utilization, high-severity patients and uses a team of “primary care intensivists,” specifically trained in care for complex patients with multiple chronic diseases, working  in concert with area managed care organizations and care providers, with estimated savings of over $11 million during the funding time frame. Over the three-year period, the University of New Mexico Health Sciences Center’s program will train an estimated 150-300 workers, while creating an estimated 8 new jobs. These workers will help increase primary care physicians’ capacity to treat and manage complex patients.

UPPER SAN JUAN HEALTH SERVICE DISTRICT
Project Title:  “Southwest Colorado cardiac and stroke care”  
Geographic Reach: Colorado
Funding Amount: $1,724,581
Estimated 3-Year Savings: $8.1 million
Summary:  The Upper San Juan Health Service District is receiving an award to expand access to specialists and improve the quality of acute care in rural and remote areas of southwestern Colorado. Their care delivery model will offer cardiovascular early detection and wellness programs, implement a telemedicine acute stroke care program, use telemedicine and remote diagnostics for cardiologist consultations, and upgrade and retrain its Emergency Medical Services Division (EMS) to manage urgent care transports and in-home follow-up patient care for over 3400 patients in medically underserved areas in Southwest Colorado. The program will provide access to cardiologists and neurologists and is expected to reduce cardiovascular risk, improve patient outcomes, create healthier communities, and reduce health care costs with estimated savings of approximately $8.1 million. Over the three-year period, the Upper San Juan Health Service District’s program will train an estimated 25 paramedics and telehealth clinicians and create 13 new jobs. These workers will provide a new type of clinical team that will improve care outcomes for rural cardiovascular patients.

VANDERBILT UNIVERSITY MEDICAL CENTER
Project Title: “Reducing hospitalizations in Medicare beneficiaries; a collaboration between acute and post-acute care”
Geographic Reach: Tennessee
Funding Amount: $2,449,241
Estimated 3-Year Savings: $8.7 million
Summary:  Vanderbilt University Medical Center, in partnership with National HealthCare Corporation, is receiving an award for a program designed to reduce inpatient re-hospitalization by 17 percent and improve patient experience for approximately 27,000 Medicare and beneficiaries dually eligible for Medicare and Medicaid in ten counties in Tennessee, including rural and underserved areas. Their project will offer improved hospital discharge planning, evidence-based interventions, and improved clinical responsiveness at post-acute facilities with estimated savings of approximately $8.7 million. Over the three-year period, Vanderbilt University Medical Center’s program will train an estimated 30 health care workers and create an estimated 4.6 new jobs. These workers will coordinate discharge planning and care transitions for patients and help integrate clinical responsiveness into post-acute care settings.

WOMEN & INFANTS HOSPITAL OF RHODE ISLAND
Project Title:  “Partnering with parents, the medical home and community provider to improve transition services for high- risk preterm infants in Rhode Island”
Geographic Reach: Rhode Island
Funding Amount: $3,261,494
Estimated 3-Year Savings: $3.7 million
Summary: The Women and Infants Hospital of Rhode Island is receiving an award to improve services for approximately 2,400 mothers in Rhode Island who have pre-term babies. The intervention will hire, train and deploy family care teams to offer education and support and monitor infants’ growth and development.  It will also support primary care providers who help provide care for this at-risk population. The result is expected to be reduced emergency room visits, fewer hospital readmissions, and decreased neonatal morbidity. This approach is expected to lower cost while improving health and health care for pre-term babies in Rhode Island with estimated savings of approximately $3.7 million. Over the three-year period, Women & Infants Hospital of Rhode Island’s program will train an estimated 120 health care workers, while creating an estimated 13 new jobs. The program will train and deploy these workers as part of Family Care Teams to offer education and support and monitor infants’ growth and development.

To learn more about other innovative models being tested by CMS’ Innovation Center, visit innovation.cms.gov.