CMS Innovation Center launches patient-centered medical neighborhood

Approximately 157,000 Medicare and Medicaid beneficiaries in up to 15 U.S. health systems and providers will begin participating in a patient-centered medical neighborhood (PCMN) demonstration project as part of a collaboration among TransforMED, Phytel and VHA. Funded by a three-year, $20.75 million cooperative agreement awarded by the Center for Medicare and Medicaid Innovation, the PCMN project is scheduled to begin implementation this month.

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 new approaches to improving healthcare and lowering program costs for recipients of Medicare, Medicaid and the Children's Health Insurance Program.

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. PCMHs connect primary care with other community-based healthcare providers to develop the "Patient-Centered Medical Neighborhood" concept. 

The collaborative PCMN project plans to achieve the following goals by year three of the demonstration:

• Decrease overall healthcare costs by $49.5 million within the 15 communities;
• Improve the health of the eligible patient population by a 15 percent average in selected quality measures;
• Achieve a 25 percent improvement in the patient experience; and
• Extend PCMH and patient-centered medical neighborhood learning within each of the 15 communities.

Healthcare organizations currently participating in the PCMN demonstration project are:

• Avera St. Anthony's Hospital in O'Neill, Neb.
• Charleston Area Medical Center in Charleston, W.Va.
• Columbus Regional in Columbus, Ind.
• Greater Baltimore Medical Center in Baltimore
• Huntsville Hospital in Huntsville, Ala.
• INTEGRIS Health in Oklahoma City, Okla.
• Marquette General Health in Marquette, Mich.
• Northeast Georgia Health System in Gainesville, Ga.
• North Mississippi Health Services in Tupelo, Miss.
• North Shore Physicians Group in Salem, Mass.
• Novant Health in Winston-Salem, N.C.
• Orlando Health in Orlando, Fla.
• Owensboro Medical Health System in Owensboro, Ky.
• Via Christi Health in Wichita, Kan.
• Western Connecticut Health Network in Danbury, Conn.

The collaboration will leverage TransforMED's PCMH primary care technologies with Phytel's population health management tool to identify and automate care gaps, patient outreach, care management, patient engagement and performance evaluation. VHA will head clinical quality improvement and knowledge transfer strategies.