Transitional care teams for rural patients with complex illness

Program Location: 
Iowa City, IA
Payer Type: 
Commercial payers

The University of Iowa, in partnership with the 11 hospitals comprising its Critical Access Hospital Network, is receiving a Health Care Innovation Award to improve care coordination and communication with practitioners in ten rural Iowa counties. The program will serve Medicare, Medicaid, and Medicare/Medicaid dual eligible beneficiaries and privately insured and uninsured patients who have complex illness, including psychiatric disorders, heart disease, kidney disease, cancer, endocrine and gastrointestinal disorders, and geriatric issues.

The program will coordinate care through teams comprised of nurses, social workers, and pharmacists along with specialty physicians (including psychiatrists) using telehealth and web-based personal health records. The program is based on the University of Iowa's significant past experience in creating telehealth care teams for patients with diabetes, chronic obstructive pulmonary disease, and heart failure. It will increase access to services and specialty care, improve care transitions and care coordination, and decrease avoidable hospital readmissions of complex patients in rural counties in Iowa.


Payment Model: 

The University of Iowa Critical Access Hospital Network will receive $7.7 million over three years.  

Last updated April 2014
Go to top