Patient Care Intervention Center
  • Patient Stories

    Integrated Client Journey

    • Partnership with United Way of Greater Houston
    • Revolutionizing modern healthcare
    • Innovating community engaged care

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  • Patient Stories

    Humanizing Healthcare - one life at a time

    • Small populations needing BIG impact
    • People struggling to overcome system barriers

    Learn how lives are being transformed.

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  • Coping with COVID-19
  • Patient Stories

    Humans of Healthcare

    • Faces that fuel our fire
    • Stories that ignite change
    • Lives being transformed

    Learn how Timmy's life was transformed.

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  • Unified Care Continuum Platform

    Unified Care Continuum Platform

    Providing a single point of access to shared patients care plan, spanning services rendered to the client from multiple organizations.

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  • Care Coordination Services

    Care Coordination Services

    • Values-based care
    • Shared care plans
    • Address social determinants

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  • Outcomes

    Outcomes

    • Improved quality of life for clients
    • Better health means lower healthcare costs
    • Systems-level impact

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Serving our clients since 2013 in care coordination, technology, and research.

UCCP Technology

UCCP Technology

Facilitating care management for complex clients through shared records and data.

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Data Analysis Services

Data Analysis Services

Analyzing population health through linked social and medical data sets.

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Care Coordination

PCIC Care Coordination

Serving individuals with complex needs, helping identify and address root causes of poor health.

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Generating Evidence

Generating Evidence

Rigorous tracking and outcomes analyses to refine best practices and effect systems-level change.

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  • PCIC Patients
  • PCIC Patients
  • PCIC Patients
  • PCIC Patients
  • PCIC Patients
  • PCIC Patients
  • PCIC Patients
  • PCIC Patients
  • PCIC Patients
  • Ms. Wills

    Ms. Wills, started with the coordinated care program with a total of 47 ER Visits, 4 Chronic Health Conditions. She was very open to changing her health for the better.

    Ms. Wills' main value was spending more time with family and grandchildren and to gain independence while taking control of her health.

    Ms. Wills stated “PCIC has really helped me improve my health by getting me into the right physicians and receiving the right medications that I needed to improve my health”.

    Read other stories
  • Ms. Warren

    Ms. Warren is a loving and funny woman who hopes to reunite with her disabled brother.

    Ms. Warren valued her role as caregiver to her brother, picking up where her mother left off and was determined to get out of her wheelchair and walking on a prosthetic leg.

    PCIC assisted Ms. Warren by being an advocate and support. PCIC attended appointments ensuring Ms. Warren’s mental health concerns were properly addressed proactively without the need for hospitalization and making sure she received medications to assist with her pre-existing and newly diagnosed conditions.

    Read other stories
  • Mr. Trondail

    Mr. Trondail is an ambitious man who hopes to reunite with his son and return to school to finish his degree, but he is also homeless and suffers from a chronic condition he has neglected for years. Like many High-Need, High-Cost patients he had a difficult time managing his health because his values continued to be overlooked.

    The one aspect of his life, other than his son, that he values most– his dog Striphe (pronounced Stripe) – continued to be a missed opportunity in a medicalized approach to health.

    With 12 Emergency Room visits and 2 hospitalizations under his belt in the span of year, Mr. Trondail continued to have poor outcomes that were continuously exacerbated by systemic barriers – he was not able to get housing, a job, or regularly access expensive medicines he desperately needed.

    Read other stories
  • Mr. Lee

    Until early 2000, Mr. Lee worked as a surveyor in Texas and enjoyed the outdoors. However, he caught our attention as a likely High-Need, High-Cost candidate in early 2015 because of his repeated 911 calls. When we reached out to him, we found him wheelchair-bound, enslaved to alcohol, severely undernourished and alone.

    He was lying in bed, soiled and hungry from going days without eating. He said he wanted to end his life.

    Until PCIC came into Mr. Lee's life, his family had thought he was a 'lost cause' since he had given up on himself. With the help of our team, his health continues to improve and he's able to manage his pain and alcohol dependency.

    His family once again is taking an active part in his life and he no longer needs to call 911 for medical care.

    Read other stories
  • Ms. Cecelia

    After the death of her mother, Ms. Cecelia lost her life-long companion and primary care-taker.

    Unable to live independently, her living conditions and medical care took a sharp decline.

    Constant falls and HFD transports related to unmanaged diabetes and congestive heart failure made it difficult for Ms. Cecelia and her family to cope.

    After PCIC's intervention, Ms. Cecelia transitioned to a supportive nursing facility and connected with specialty physicians focused on stabilizing her conditions.

    She has had a 81% reduction in ER visits and hospital admissions.

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  • Mr. Jesse

    Sleeping on a bench outside his family home, Mr. Jesse constantly cycled in and out of the ER as his blood sugars alternatively spiked and plummeted.

    Without consistent access to food or insulin, he struggled to manage a particularly treatment-resistant case of type 2 diabetes.

    Years of struggling with unmanaged diabetes and homelessness had left him in chronic pain and without hope.

    PCIC and Mr. Jesse worked together to find a new home and connect him with the medical and social services he needed.

    Since PCIC's intervention, Mr. Jesse is stably housed and well-supported with a 50% reduction in ER visits and hospital admissions.

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  • Mr. Randy

    Randy worked on an oil rig, and after enduring a traumatic injury on the job, his life became challenging as he lost his job, his family, and his home.

    Feeling discouraged, he became an alcoholic and enrolled in rehabilitation programs; but that did not help him address the unknown causes for his seizures.

    Because he was homeless, 911 was usually called by a bystander who witnessed the seizures.

    Having attended several programs that failed him, he was surprised and pleased to see that PCIC was consistent and passionate about helping him.

    Through care coordination we connected him with a primary care physician, decreased his ER visits, and he hasn't had a seizure since enrolling.

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  • Mr. Ercell

    When PCIC met Mr. Ercell, he struggled to stand up from his couch due to the fluid build-up around his lungs.

    Without a PCP or specialist, Mr. Ercell did not know how to manage his congestive heart failure and high blood pressure.

    Constant visits back and forth to the ER left him feeling adrift in the healthcare system.

    Once he was connected with outpatient physicians, he lost nearly 60 lbs in fluid and dramatically improved his mobility.

    Since PCIC's intervention, Mr. Ercell went from 15 ER visits and 9 admissions to 0 ER visits or hospital admissions.

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  • Mr. Timmy

    He's HIV-positive and lives with amputated legs. Timmy lived near the largest medical center in the world, but when it came to getting access to a system that could help him care for serious, chronic health conditions, Timmy didn't know where to turn.

    The PCIC team followed Timmy to the hospital. They monitored his daily progress and after he was released, the team made visits to his apartment to coordinate all aspects of his healthcare.

    They connected him with a PCP, helped him get access to needed medications, secured home health providers, and even went along to doctor's appointments.

    Timmy was now part of a coordinated system through PCIC addressing the underlying causes of his health problems, long before the symptoms became severe.

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  • Ms. Cynthia

    Hungry. Homeless. Ms. Cynthia, a diabetic, and former drug addict struggled with high blood pressure and lupus.

    She frequently called 911 when she didn't feel well. Missed doctor appointments were the norm due to transportation challenges and a disengaged partner became detrimental. Realizing she'd hit rock bottom, she was open to help.

    PCIC reached out setting up dependable transportation to keep her appointments.

    She has continued to lean on us for support when reverting to unhealthy patterns and has built a new confidence enabling better control of her diabetes.

    Read other stories
  • Mr. Travis

    Suffering from priapism and high blood pressure, Mr. Travis, a timid and shy man felt hopeless and depressed.

    When asked what he should do when he had flare ups, a health professional directed him to "just call 911", and prescribed him counter-productive medications.

    PCIC intervened to coordinate his care. We found him a new doctor, helped guide dietary and lifestyle changes, and nourished his will to live.

    A new confidence and motivation enabled him to self-advocate resulting in a 75% reduction of ER calls, and most importantly, he was now in control of his life.

    Read other stories

What our clients, funders, stakeholders say


  • Aaron Truchil

    The Camden Coalition's partnership with PCIC to augment the Coalition's data and IT infrastructure has been incredibly fruitful. Our care teams are now equipped to engage their clients in real-time as they are admitted to the hospital, a critical time for ensuring smooth transitions before individuals are discharged back into the community.

    PCIC has helped us think through some of our long term data needs and execute on a number of time-sensitive projects. It has enabled better integration of data across all of the Coalition's disparate data platforms, including our regional Health Information exchange and the Coalition's care management database.

    Aaron Truchil Director of Strategy and Analytics - Camden Coalition of Healthcare Providers
  • Ms. Wills

    Molina Healthcare and PCIC have really helped me improve my health by helping me get to the right doctors and coordinating the medications I need to improve my health.

    I really hate to leave the program because my case worker, Markisa, was so sweet and kind. I thank y'all for helping me.

    Ms. Wills PCIC Graduated Client
  • Suzanne Jarvis

    We serve complex, high cost clients. PCIC confirmed it. Now we clearly see the community providers that also serve our clients. The usage patterns and costs are staggering.

    PCIC provides a platform to develop systems of care coordination to improve health outcomes. This opens a brand new door to preserve community resources and manage population health.

    Suzanne Jarvis Program Manager - Houston Recovery Center
  • Mr. Curtis

    I don't trust everybody and whenever my mind begins to wonder or I got sick you all were just a phone call away. Thank you for helping me in almost my darkest hour.

    Mr. Curtis PCIC graduated client

Unified Care Continuum Platform



Our Unified Care Continuum Platform (UCCP) empowers medical and social agencies to collaboratively identify and address social determinants of health.

The Platform:
  • Merges social and medical records
  • Facilitates cross-agency care coordination
  • Connects the right resource to the right person
  • Generates data to support systems-level change

Learn more

HL7® and FHIR® are registered trademarks of Health Level Seven International.

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Our Mission

Improve healthcare quality and costs for the vulnerable in our community through data integration and care coordination.

We Envision

Coordinated health safety-net where all stakeholders share data to make better decisions.

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