Health Care Innovation Awards: Delaware

Notes and Disclaimers:

• Projects shown may also have operated 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 were 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.

ATLANTIC GENERAL HOSPITAL CORPORATION

Project Title: “Expand Atlantic General Hospital’s infrastructure to create a patient-centered medical home”
Geographic Reach: Delaware, Maryland
Funding Amount: $1,097,512
Estimated 3-Year Savings: $3,522,000

Summary: Atlantic General Hospital Corporation, which serves largely rural Worcester County, Maryland, is working to improve care for Medicare beneficiaries through a patient centered medical home (PCMH) care model. Through a partnership with the Worcester County Health Department (WCHD), Atlantic General has implemented PCMH standards and principles in all seven of its primary care practices, increasing access for patients needing non-emergency episodic care to reduce hospital admission rates and emergency department visits for these Medicare beneficiaries. The original intent of the grant-funded project was to focus on patients with either a primary or admitting diagnosis of congestive heart failure, chronic obstructive pulmonary disease (COPD), or diabetes, who currently rely on high-cost ER visits and acute care admissions. However, the PCMH team has been able to expand the program to offer services to patients with additional diagnoses.

CHRISTIANA CARE HEALTH SYSTEM

Project Title: “Bridging the Divides”
Geographic Reach: Delaware
Funding Amount: $9,999,999
Estimated 3-Year Savings: $376,327

Summary: Christiana Care Health System, serving the state of Delaware, received an award to create and test a system that uses a ”care management hub” and combines information technology and carefully coordinated care management to improve care for post-myocardial infarction and revascularization patients, the majority of them Medicare or Medicaid beneficiaries. Christiana Care will integrate statewide health information exchange data with cardiac care registries from the American College of Cardiology and the Society of Thoracic Surgeons, enabling more effective care/case management through near real time visibility of patient care events, lab results, and testing. This will decrease emergency room visits and avoidable readmissions to hospitals and improve interventions and care transitions. The investments made by this grant are expected to generate cost savings beyond the three year grant period. Over a three-year period, Christiana Care Health System will create an estimated 16 health care jobs, including positions for nurse care managers, pharmacists, and social workers.

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 serving prediabetic Medicare beneficiaries in 17 communities across 8 states in the U.S. The intervention delivers community-based diabetes prevention through a nationally-recognized diabetes prevention lifestyle change program, coordinated and taught by trained YMCA Lifestyle Coaches. The goal is to prevent the progression of prediabetes 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, a grant administrator, a workforce development manager, data specialists, training specialists, and administrative coordinator.

NEMOURS ALFRED I. DUPONT HOSPITAL FOR CHILDREN

Project Title: "Optimizing health outcomes for children with asthma in Delaware"
Geographic Reach: Delaware
Funding Amount: $3,697,300
Estimated 3-Year Savings: $4,743,184

Summary: Nemours/ Alfred I. duPont Hospital for Children, partnering with Delaware Health and Social Services, Division of Medicaid and Medical Assistance, and Division of Public Health, the South Wilmington Planning Network, Healthy Kids Collaboration in Kent County, Sussex County Health Promotion Coalition, and United Way of Delaware, received an award to enhance family-centered medical homes by adding services for children with asthma and developing a population health initiative in the neighborhoods surrounding targeted primary care practices. The intervention also increases coordination of services by integrating care with community support services and local government initiatives to provide healthier environments for children with asthma in schools, child care centers, and housing, and by deploying community health workers to serve as patient navigators and provide case management services to families with high needs. The goal of this model is to reduce asthma-related emergency room use and asthma-related hospitalization among pediatric Medicaid patients in Delaware by 50% by 2015 with incremental declines in 2013 and 2014. This goal will be accomplished by focusing on three distinct strategies: 1. Enhancement of the family-centered medical home by adding new services for children with asthma and developing a well-coordinated interdisciplinary approach to managing asthma care; 2. Development of a sustainable network of evidence-based supports and services surrounding each of the three targeted primary care sites, using the “integrator” model that Nemours has already adopted; and 3. Deployment of a “navigator” workforce that incorporates non-medical needs into the provision of care for children with asthma that promotes respiratory health and addresses environmental asthma triggers throughout the target communities.

THE TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA

Project Title: “A rapid cycle approach to improving medication adherence through incentives and remote monitoring for coronary artery disease patients”
Geographic Reach: Delaware, New Jersey, New York, Pennsylvania
Funding Amount: $4,841,221
Estimated 3-Year Savings: $2,787,030

Summary: The University of Pennsylvania received an award for a program to improve medication adherence and health outcomes in patients who have recently been discharged from the hospital with acute myocardial infarction.  Such patients typically have high rates of poor medication adherence and hospital readmissions and are costly to monitor through intensive case management. The intervention will increase medication adherence through remote monitoring, medication reminders, incentives, and support from family and friends. It will also retrain social workers as engagement advisors to provide additional support as needed. The result will be improved health outcomes and lower cost. The investments made by this grant are expected to generate cost savings beyond the three year grant period. Over a three-year period, University of Pennsylvania’s program will train an estimated 21 workers, while creating an estimated seven jobs for investigators, clinical social workers, a software developer, project coordinators, and a project director.

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