California

The goal of the Collaborative Accountable Care (CAC) program is to better coordinate care. Primary care and specialty care doctors will work together toward improved quality, better health outcomes and lower health care costs. Critical to the program's benefits are clinical care coordinators, including nurses, physicians, and other professionals, employed by Brown & Toland, who help patients with chronic conditions or other health challenges navigate the health care system.

Cigna and HealthCare Partners Medical Group in Southern California launched a collaborative accountable care initiative to improve patient access to healthcare, enhance care coordination, and achieve the “triple aim” of improved health, affordability and patient experience. The program became effective April 1, 2013.

LifeLong Medical Care is receiving a CMS Health Care Innovation Award to further integrate care and encourage healthy behavior among 3250 seniors and other adults with disabilities who are Medicaid and dual Medicare/Medicaid-eligible beneficiaries. The goal is to reduce avoidable emergency room and hospital visits. The intervention will train adults with disabilities to support adoption of healthy behaviors among their peers and to encourage self management, with the support of a team of nurse care managers.

The Humboldt County-AF4Q initiative is a collaborative project of many local organizations and individuals interested in improving the quality of health care. The effort fosters a high-quality, integrated, patient-centered system of care that is accessible to all North Coast residents. The project has three aims - provider measurement and public reporting, patient involvement, and medical care improvement activities - to improve the medical care and self-care of patients, particularly those with diabetes.

Sutter Health is recieving a $13,000,000 CMS Health Care Innovation Award to expand their Advanced Illness Management program (AIM) across the entire Sutter Health system in Northern California, serving patients who have severe chronic illness but are not ready for hospice care, are in clinical, functional, or nutritional decline, and are high-level consumers of health care.

The Pacific Business Group on Health (PBGH) is receiving a CMS Health Care Innovation Award to work with various provider groups and health plans in rural and urban counties throughout California to improve care coordination for 30,000 Medicare and dual-eligible Medicare-Medicaid beneficiaries at risk from multiple chronic conditions. The Intensive Outpatient Care Program uses well trained care managers embedded in high-performing primary care teams to develop close relationships with medically complex patients and deliver highly individualized and accessible primary care, based on treatmen

The Regents of the University of California, Los Angeles, are receiving a CMS Health Care Innovation Award to expand a new program to provide coordinated, comprehensive, patient and family-centered, and efficient care for approximately 1000 Medicare and Medicaid beneficiaries with Alzheimer's disease or other forms of dementia. The UCLA Health System operates in the western area of Los Angeles County.

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 a CMS Health Care Innovation 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, California. 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.

Cigna and the Palo Alto Medical Foundation (PAMF), a not-for-profit health care organization that is a pioneer in the multi-specialty group practice of medicine, have launched a collaborative accountable care initiative to expand patient access to health care, improve care coordination, and achieve the “triple aim” of improved health outcomes (quality), lower total medical costs and increased patient satisfaction. It links doctors, hospitals and a single health plan together with the goal of reducing health care costs by improving patients' health.

The University of Southern California is receiving a CMS Health Care Innovation Award to integrate clinical pharmacy services into safety net clinics, providing medication therapy management, disease state management, medicine reconciliation, medication access services, patient counseling, drug information education, preventive care programs, provider education, and quality improvement review for care providers and for the underserved and vulnerable populations of Santa Ana, Huntington Beach, and Garden Grove.