A $20.75 million federal grant will fund a three-year project to expand patient-centered medical homes in 16 communities to patient-centered medical “neighborhoods.”

Three sponsoring organizations will provide technologies and services to primary care, specialty and sub-subspecialty physician practices, as well as acute care hospitals. The grant comes from the CMS Center for Medicare and Medicaid Innovation under the $1 billion Health Care Innovation Awards program authorized in the Affordable Care Act.

Provider alliance VHA Inc., the TransforMED subsidiary of the American Academy of Family Physicians, and population health management software vendor Phytel comprise the partnership that received the grant.

Phytel’s software will automate identification of gaps in care, patient outreach and engagement activities, care management and performance evaluation. VHA will add its knowledge of quality management and ambulatory care strategies for hospitals, and TransforMED will contribute expertise in building patient-centered medical homes. The organizations estimate the project could save Medicare $53 million over three years.

Participating communities are Allegiance Health in Jackson, Mich.; Avera St. Anthony’s Hospital in O’Neill, Neb.; Charleston (WVa.) Area Medical Center; Columbus  (Ind.) Regional Health; Elmhurst (Ill.) Clinic; Gundersen Lutheran Health System in La Cross, Wis.; Huntsville (Ala.) Hospital; and Integris Health in Oklahoma City.

Also: Marquette (Mich.) General Health System; Northeast Georgia Health System in Gainesville; North Mississippi Health Services in Tupelo; North Shore Physicians Group in Salem, Mass.; Orlando Health in Florida; Owensboro (Ky.) Medical Health System; Via Christi Health in Wichita, Kan.; and Western Connecticut Health Network in Connecticut. Participants will share their best practices.

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