This award is part of the Health Care Innovation Awards program, a Department of Health and Human Services initiative investing up to $1 billion to test promising new approaches that aim to improve health care and lower program costs for recipients of Medicare, Medicaid and the Children's Health Insurance Program (CHIP).
TransforMED, VHA and Phytel will support up to six primary care practice transformation efforts within each participating community to create or continue development of Patient-Centered Medical Homes (PCMHs) into Patient Centered Medical Neighborhoods (PCMN). PCMHs connect primary care with other community-based health care providers to develop the "Patient-Centered Medical Neighborhood" concept. Designed to improve and strengthen collaborative relationships among primary care practices and other providers such as hospitals and specialists, the PCMN builds on proven methodologies and solutions to create more efficient, coordinated health care delivery networks that improve care at a lower cost.
The collaborative PCMN project plans to achieve the following goals by year three of the demonstration:
The collaboration will leverage TransforMED's PCMH primary care expertise with Phytel's population health management solution to identify and automate care gaps, patient outreach, care management, patient engagement, and performance evaluation. VHA will bring expertise in clinical quality improvement and knowledge transfer strategies. This potent combination is expected to yield significant improvements in clinical integration and clinical outcomes at lower costs.
