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Avera’s Coordinated Care Model Earns Recognition

May 24, 2015 04:48PM, Published by MED Magazine, Categories: In Print, News



Avera’s Coordinated Care program has been recognized among the top five of health organizations that participated in a Center for Medicare & Medicaid Innovation (CMMI) Health Care Innovation Challenge Grant.

Since 2012, Avera’s Coordinated Care model has participated in this project, through CMMI grant funding received by a collaborative partnership that includes VHA Inc., a national network of not-for-profit health care organizations; TransforMED, a not-for-profit subsidiary of the American Academy of Family Physicians; and, Phytel, Inc., a technology company that leads the field in automated, provider-led population health improvement solutions.

The grant funded a three-year national project involving healthcare systems, hospitals, and provider practices throughout 16 communities, one of which was O’Neill, Nebraska, home to Avera St. Anthony’s Hospital.

The goal of the project was 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.

Coordinated Care is specifically designed to help people who have significant barriers to improved health, such as multiple diagnoses, catastrophic illness, health literacy issues, or psychosocial issues such as lack of finances, depression, or lack of health insurance.

There are eight Coordinated Care teams throughout the Avera system. Each team is comprised of an RN as team coordinator, a clinic care specialist, and a social worker. This will expand to 13 teams by the end of the year. Currently, 954 patients are active in the program.

“Over the past few years, we've seen great success in patient outcomes through the Coordinated Care concept. The future of medicine will center on prevention and better management of illness, rather than hospital treatment of illness. Our Coordinated Care teams are breaking new ground to help patients overcome significant challenges, and return to better health,” said Tad Jacobs, DO, Chief Medical Officer for Avera Medical Group.  


avera coordinated care


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