Innovation Challenges



Congratulations to the Five Winners of the inaugural Trinity Health Innovation Challenge "Reducing Readmissions for Dual Eligible Patients"


October, 2016

Earlier this year, Trinity Health launched its inaugural Innovation Challenge, intended to help identify, fund and implement ideas aimed at reducing readmission rates and improving care for patients who are dually eligible for Medicare and Medicaid. The applicants for this award were submitted by Trinity Health ministries, the system office and organizations external to Trinity Health that were willing to work with a Trinity Health ACO or bundled payment program to implement, test and replicate a solution.

Congratulations to the following winners whose innovations were chosen from 67 internal and external applicants from around the country:

"Employing Older Adults as Companions with a New Technology to Reduce Hospital Admissions" (AgeWell Global in partnership with Holy Cross Hospital, Fort Lauderdale, FL)

AgeWell integrates a human service model with innovative technology to address health problems of older adults recently discharged from hospital. Older adults with chronic medical problems are at high risk for readmission.

"Applied Artificial Intelligence to Stop Dual Eligible Patient Readmissions" (Jvion, in partnership with St. Joseph Health, Syracuse, NY)

Through the Trinity Health Innovation Challenge, we will build, test, and deploy a predictive use case designed around dual eligible patient readmissions. While we currently have a readmission use case, we will extend the model to address the complex challenges faced by the dual eligible patient population.

"Community Aging in Place, Advancing Better Living for Elders (CAPABLE)" (Mercy Health Muskegon - Mercy Campus, Muskegon, MI)

CAPABLE is a patient-centered approach to home healthcare, pioneered as a CMS Innovation Center program in Baltimore, MD. The program's intervention involves the deployment of a three person team (a nurse, an occupational therapist, & a handy man) to the homes of older adults who are dually-eligible for Medicare and Medicaid. The program's intervention involves the deployment of a three person team (a nurse, an occupational therapist, & a handy man) to the homes of older adults who are dually-eligible

"Whatever it Takes: A 24/7 Triage and PRN Treatment Service" (Trinity Health At Home)

(PRISM-stratified) high risk dual-eligible patients discharged from SJMH-AA with SJM Home Care (HHA) will be sent home with a personal care response system (PERS). Whether the patient presses their PERS button, calls the nurse triage line or dials 911, a prn 24/7 triage service that includes an EMS provider (HVA), an ER group (EPMG) and a social service agency partner (Catholic Social Services - CSS).

Whatever It Takes: Building a Healthcare System like "Cheers" (Where Everyone Knows Your Name)

"Hospital at Home" (Trinity Health At Home)

Hospital at Home is an innovative care model that provides patient evaluation and management services usually performed in the traditional acute inpatient hospital setting, in a patient's home.  Hospital at Home operates as a distinct or virtual, but integrated ward of a hospital, but without the usual bricks and mortar surrounding the hospital bed.


Trinity Health is funding each of the winning innovations with as much as $350,000. The funding was awarded to applicants that proposed an entirely new model of care or an "adapted" model that has been previously implemented. Adapted solutions built upon a successful model previously tested while piloting an approach that is a new and /or unique service for dual eligible patients at Trinity Health.

"The grants we award to each of the winners will be used to fund their innovative, breakthrough ideas and associated project plans," said Anna Marie Butrie, vice president, Innovation Program and Services for Trinity Health. "These innovations were designed specifically to help us better serve some of the most vulnerable patients in our communities in a compassionate and transformative way."

In the U.S., nearly 11 million people are covered by both Medicare and Medicaid. These "dual eligible" patients represent a group comprised of low-income seniors and younger people with disabilities whose care is frequently very complicated and challenging.

According to the Henry J. Kaiser Foundation, some of the key characteristics that distinguish dual eligible patients from typical Medicare beneficiaries include:

• Very low incomes (55 percent have annual incomes below $10,000, compared to six percent of other Medicare beneficiaries)

• Substantial health needs (half are in fair or poor health, more than twice the Medicare rate)

• More likely to have mental health needs

• More likely to live in nursing homes

Dual eligible patients also have higher 30-day and 90-day readmission rates. During a recent three-month period, dual eligible patients cared for by Trinity Health's Accountable Care Organizations experienced readmission rates about 106 percent higher than that of non-dual eligible patients.