INTEGRIS Health Medical Neighborhood Demonstration - Oklahoma

Program Location: 
Oklahoma City, OK
Payer Type: 
Partner Organizations: 

Reported Outcomes


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 promising new approaches that aim to improve health care and lower program costs for recipients of Medicare, Medicaid and the Children's Health Insurance Program (CHIP).

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 (PCMN). PCMHs connect primary care with other community-based health care providers to develop the "Patient-Centered Medical Neighborhood" concept. Designed to improve and strengthen collaborative relationships among primary care practices and other providers such as hospitals and specialists, the PCMN builds on proven methodologies and solutions to create more efficient, coordinated health care delivery networks that improve care at a lower cost.

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

  • Decrease overall health care 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
  • Extend Patient-Centered Medical Home and Patient-Centered Medical Neighborhood learning within each of the 15 communities

The collaboration will leverage TransforMED's PCMH primary care expertise with Phytel's population health management solution to identify and automate care gaps, patient outreach, care management, patient engagement, and performance evaluation. VHA will bring expertise in clinical quality improvement and knowledge transfer strategies. This potent combination is expected to yield significant improvements in clinical integration and clinical outcomes at lower costs.  

Payment Model: 

Funded by a three-year, $20.75 million cooperative agreement awarded by the Center for Medicare and Medicaid Innovation.

Fewer ED / Hospital Visits: 

43.6% Reduction 30 Day All Cause Readmissions

Improved Health: 

20.3% Improvement Quality Monitoring & Control

Cost Savings: 

15.9% Reduction PMPM Costs

27.3% Reduction Inpatient Costs

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