A three-year "medical neighborhood" demonstration project using health information technology to identify high-risk patients and coordinate their care is getting started, and it's being paid for with a $20.75 million grant from the Center for Medicare and Medicaid Innovation. The center expects it will see more than $53.8 million in savings from the participating 15 healthcare organizations, which provide care for some 157,000 Medicare and Medicaid beneficiaries.

The grant was awarded in June and will cover services provided by TransforMED, a medical-home consulting service owned by the American Academy of Family Physicians; VHA, an Irving, Texas-based national network of not-for-profit healthcare organizations; and Phytel, a Dallas-based provider of population health-management tools.

The organizations will help as many as six primary-care practices in participating communities transition to the patient-centered medical-home model, which emphasizes coordinated care, increased care access and continuous quality improvement. The intent then is to connect the practices with other providers in the communities to create a medical neighborhood network, according to a TransforMED news release.

"The project will use a sophisticated analytics engine to identify high-risk patients and coordinate care across the medical neighborhood while driving PCMH transformation in a number of primary-care practices in each community," according to the CMMI website. "Truly comprehensive care will improve care transitions and reduce unnecessary testing, leading to lower costs with better outcomes."

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

"It's a great time to be a primary-care physician, and we are eager to get started on this exciting project," Dr. Terry McGeeney, TransforMED CEO, said in the release.

McGeeney, who serves as the project's executive sponsor, added that a project goal includes creating "the ideal situation for our nation's healthcare system through this award," by building a strong primary-care foundation that coordinates care between health systems and specialists.

Another stated goal was to share best practices developed in the demonstration with other VHA-affiliated hospitals. Other medical-home pilots have been criticized as being designed in such a way that they're unable to show a definite link between interventions and outcomes. TransforMED, Phytel and VHA did not respond before deadline to a question about how this concern will be addressed.