A CMMI Health Care Innovation Award (HCIA) Challenge grant was awarded to TransforMED, a not-for-profit subsidiary of the American Academy of Family Physicians. Project affiliates include VHA Inc., the national health care network; Phytel, Inc., a technology vendor that leads the field in automated, provider-led population health improvement solutions; and Cobalt Talon, a provider of high-performance analytic and data management products and services for health care.
The grant will fund a three-year national project involving health care systems, hospitals, and provider practices in 15 communities. The goal of the project is to expand the concept of the Patient-Centered Medical Home to the Patient-Centered Medical Neighborhood and connect acute-care hospitals with primary care, specialty and subspecialty practices to drive better quality and superior patient experience at a more affordable cost.
By combining TransforMED’s Patient-Centered Medical Home primary care transformation expertise with Phytel’s population health management tools and technology systems and Cobalt Talon’s data products within communities of participating VHA member health care organizations, the collaborative partners intend to achieve more effective and efficient patient care and health care system outcomes.
Building on the foundation of existing business relationships, TransforMED, VHA, Phytel and Cobalt Talon will deploy an innovative model that is built on four pillars:
- TransforMED’s success in assisting thousands of primary care practices and health care systems become effective Patient-Centered Medical Homes (PCMH) in markets across America over the past six years.
- VHA Inc.’s national leadership in creating learning collaboratives and providing, analytics, knowledge and expertise to member hospitals and health systems in the areas of clinical, operational and financial improvement.
- Phytel’s suite of technology solutions for automating population health management, care coordination, and patient engagement for ambulatory care organizations.
- Cobalt Talon’s ability to transform data into a strategic asset by providing high-performance analytic and data management products and services.