Health Care Innovation Awards Round Two: North Carolina

Notes and Disclaimers:

• Projects shown may also be operating in other states (see the Geographic Reach)

FOUR SEASONS COMPASSION FOR LIFE

Project Title: "Increasing patient and system value with community based palliative care"
Geographic Reach: North Carolina
Estimated Funding Amount: $9,596,123

Summary: The Four Seasons Compassion for Life project will test a new model for community-based palliative care (in conjunction with Duke University), which spans inpatient and outpatient settings. The model features interdisciplinary collaboration and the integration of palliative care into the health care system, continuity of care across transitions, and longitudinal, individualized support for patients and families. This expands upon a successful program in four Western North Carolina counties to include an additional ten counties.  With community-based palliative care, care coordination ensures clinical follow-up of patients as they transition across settings. Standardized assessments and data infrastructure facilitate quality monitoring/improvement and high-quality patient care leading to decreased hospital readmissions.

NORTH CAROLINA COMMUNITY CARE NETWORKS, INC.

Project Title: "Optimizing the Medical Neighborhood: Transforming Care Coordination through the North Carolina Community Pharmacy Enhanced Services Network"
Geographic Reach: North Carolina
Estimated Funding Amount: $15,106,050

Summary: North Carolina Community Care Networks, Inc. project will test a model focused on community based pharmacists who will deliver medication management services to patients with at least one chronic condition and have over 80% of their medications filled within the last 100 days at a specific pharmacy. The pharmacist will utilize PHARMAceHOME, a pharmacy information exchange platform, to understand both the patient's prescription history in order to deliver effective medication management services and support the coordination of care by serving as an extension of the patient centered medical home care manager. These services are expected to reduce hospital readmissions and visits to the emergency department by providing patients with the medication assistance they need proactively.

THE UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL

Project Title: "Better Back Care: A Comprehensive Strategy for Improving Function and Outcomes While Reducing Overutilization and Costs"
Geographic Reach: North Carolina
Estimated Funding Amount: $6,034,888

Summary: The University of North Carolina at Chapel Hill project will test the implementation of Better Back Care (BBC), a new care delivery model for new onset low back pain that aims to improve the patient's experience and outcomes, reduce cost of case, and deliver a supporting outpatient bundled payment methodology. BBC leverages evidence-based care in a medical neighborhood of primary and specialty care providers through a patient-centered coordinated care model that supports and educates patients and includes them in treatment decisions. The model will utilize patient education and shared decision making tools, as well as nurse patient navigators, who will coordinate with primary care providers. Over the award period, BBC aims to improve adherence to evidence-based, patient-centered practices leading to improved clinical outcomes and satisfactions, while reducing the usage of imaging, injections, and surgery for patients in a five-county area of North Carolina. BBC plans to create a medical neighborhood linking approximately 60 primary care providers in general internal medicine, family medicine, and geriatrics, with the UNC spine program, an extensive multidisciplinary team of 10 specialty providers employing evidence-based, patient-centered approaches.

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