In July 2012, Mary's Center for Maternal Child Care in Washington, D.C. was awarded a three-year, $14.9M grant from the Center for Medicare and Medicaid Innovation. Through this funding, the Capital Clinical Integrated Network (CCIN) was created to to improve care for high-utilizing chronically ill Medicaid recipients in the D.C. area, including those who rely on emergency room visits for primary health care. The project uses a city-wide database, care teams, and tele-health to improve communication with patients, develop care plans, and personally manage care as these patients gradually transition into receiving care through patient-centered medical homes. The expected results are lower cost from reduced dependence on crisis care and ER visits and better health care for people with controllable chronic conditions such as diabetes, hypertension, asthma, and co-occurring mental illness. Over this three-year period, Mary's Center for Maternal Child Care will train and hire 44 health care workers to serve as care managers and community-based care coordinators. The estimated three-year savings for this program are $17.7 million.
