What is PCIC?
The Patient Care Intervention Center (PCIC) is a non-profit organization whose mission is to improve healthcare quality and costs for the most vulnerable in our community through data integration and care coordination.
Our prime focus is on High-Need, High-Cost patients of hospitals and emergency rooms.
Through a systemic approach, we are improving patient experiences and health outcomes while lowering the cost of providing it. By coordinating and analyzing per-capita cost, and other data across multiple systems of care, we can identify care coordination strategies and incorporate best practices that have been successful in other cities.
Through customized dashboards we identify gaps in care coordination and provide a framework for measurable outcomes, improvement and cost reduction. We work across disciplines and create a more effective safety net system for our Harris County clients.
Who are the stakeholders?
We are looking to partner with all agencies that work with High-Need, High-Cost patients. Our current partners Include:
Houston Methodist Hospital Community Health Choice City of Houston Houston Fire Department Houston Police Department Healthcare for the Homeless-Houston Harris Health System Amerigroup Houston Recovery Center (Sobriety Center) The Harris Center for Mental Health and IDD Greater Houston HealthConnect Coalition for the Homeless of Houston/Harris County
If your organization is interested in participating in our county-wide efforts, please contact us.
How do we define High-Need, High-Cost patients?
We recognize that different agencies define High-Need, High-Cost patients differently, depending on the type of agency and the services being provided to the client.
At PCIC we define High-Need, High-Cost patients of the health care system as clients who have 4 or more hospital admissions OR 10 or more ER visits per year PLUS 2 or more chronic medical conditions. These High-Need, High-Cost patients typically cost over $150,000 per user per year.
What is the intervention?
We identify High-Need, High-Cost patients that meet our inclusion criteria (4+ hospital admissions and/or 10+ ER visits AND 2+ chronic medical conditions). After meeting with these clients and getting their agreement, enroll them in the program.
The program consists of intensive care coordination in which a team of coordinators (emergency medical technicians, social workers, and medical doctors) make weekly home visits as well as accompany the patient to doctors' appointments and other pertinent appointments. The care coordination team works very closely with the patient to get to the root of the high utilization, and through goal negotiated care, helps patients reach their goals by developing individualized care plans. These care plans encompass the different social and medical aspects that the patients needs in order to manage their care and have a better quality of life. Throughout the intervention, we track progress of the client through various measures including the "Daily Living Activities-20" score (to determine quality of life), the "Adverse Childhood Events" score (to measure trauma), and Ecomaps (to show support systems) and understand the barriers and enablers that the clients are facing. Our objective is to help clients manage their care independently, and find the resources needed to live as independently as possible.
- 4 or more admissions and/or 10 or more ER visits a year, AND
- 2 or more chronic conditions AND
- 3 or more of the following characteristics:
- Taking 5 or more medications
- Difficulty accessing health care services due to language barrier, low literacy, or other factors
- Lack of social support network
- Mental health disorder
- Active use of illegal drugs
- Lack of medical insurance
- Surgical procedures
- Complications of a progressive chronic disease with limited treatment
- Mental health only diagnosis with no co morbid condition
- Chronic Kidney Disease
We know who the High-Need, High-Cost patients are in our agency, and have already developed an intervention program for them. So why should we consider participating with PCIC?
High-Need, High-Cost patients who regularly cycle in and out of multiple hospitals and agencies are generally expensive to treat and difficult to engage in primary care. The impact individual programs may have is limited and does not address the problem as a whole. By sharing data with a community-wide High-Need, High-Cost patient intervention, an organization can gain effectiveness and efficiencies in care that would otherwise be outside of its capacity. Coordinating efforts have saved 10-50% in other communities. As more institutions participate in PCIC, the margin and potential to improve care AND reduce cost will increase.
What kind of data do I need to share?
To perform an initial overlap analysis and to select High-Need, High-Cost patients, we require patient demographic data, admission, discharge and transfer data, and billings/claims data for the previous 12 months. The specific data fields we initially require are:
- Patient Name
- Date of Birth
- Race and Ethnicity
- Admit Date
- Discharge Date
- Admission type (Emergency room or In-patient)
- Facility of Admission
- Insurance Information
- Admission Diagnoses
- DRG code
- Procedure codes
- Visit cost
How will it comply with HIPAA?
HIPAA permits hospitals to use and disclose their patients' protected health information (PHI); including hospital claims data, for the purposes of treatment, payment and healthcare operations without obtaining individual patient consent.
Most High-Need, High-Cost patient interventions are a form of "treatment" because they include the "provision, coordination, or management of healthcare, and related services, among health care providers, or by a health care provider with a third party."
If a hospital identifies the PCIC program as a third party that will coordinate care for its High-Need, High-Cost patients, that hospital may share information, including hospital claims data, about its patients who may be eligible for the intervention without obtaining any additional prior patient consent.
 For information about uses and disclosures for treatment, payment, and health care operations, see: Uses and Disclosures
What kinds of reports are provided?
Reporting mechanism in the PCIC web portal is divided into two categories:
- Visual Based Reporting
- Grid Based Reporting
Visualization Based Reporting provides graphical data views that are interactive and can be drilled down from an aggregate view to detailed views. Grid Based Reporting provides an interface to view data collections as grids and/or pivot tables, which can re-grouped, re-filtered and sorted dynamically.
The reporting content will consist of High-Need, High-Cost patient Identification reports (both for the aggregate dataset and the individual institution's dataset), and outcomes/assessment and evaluation reports (for both for the aggregate dataset and the individual institutions dataset). The web portal "high level design" diagram shown below displays the reporting sections, circled in red.
What kinds of dashboards are developed?
Outputs, from the patient selection process to the intervention process to post-graduation follow-ups are provided to our stakeholders in a visual manner using dashboards (on the web). These dashboards are built at different levels – from the detailed patient specific view to the provider level views to the institution level view. Our goal is to look at the data at a community level – to help better understand the needs of the entire community, which is the substance of population health.
What are the outcomes measured?
Over 400 data points are recorded and tracked during the intervention period. Client's medical history is recorded into the system. Care plans with shared goals are identified with the client. Their progress is measured using scoring mechanisms like the DLA-20 form (which is the daily living activities functional assessment score/ i.e. a quality of life measure), ACE score – adverse childhood experience, the ecomap – used to document and visualize the social and personal relationships of the patient and root cause analysis.
In addition we also track outcomes by performing pre and post intervention analysis– looking at not only these different scoring mechanisms, but also costs and visit counts to the healthcare system. The outcomes we measure are ER visits, transports, hospital admissions, PCP visits, quality of life, utilization of services (social and medical), care coordination services, social determinants of health and costs.
Who is hosting the data?
Data is hosted by PCIC on data centers that meet HIPAA compliance. In addition, PCIC data centers are audited in accordance with SSAE 16 (SOC 1 Type 2 and SOC 2 Type 2) standards.
The PCIC database environment runs on a SQL Server 2014 infrastructure with redundancies in place using clustering, automated failover environments and encrypted database backups. The PCIC application and web portal is maintained on a hardware load balanced environment with an automatic secondary failover DR environment.
What is the Community Health Council, and why do we need it?
Resources are wasted through duplication of social and health services due to limited "silo-based" views at the Community, Institution and Provider levels. This silo-based mentality, combined with limited availability of integrated data, reduces quality decisions and the effective provision of healthcare and other services. Patients receiving services from multiple silo-based providers experience fragmented, duplicative care.
This problem is especially evident in the High-Need, High-Cost population. High-Need, High-Cost patients are those who have frequent contact with the medical system without measurable improvements in their health. Of $3 trillion spent on healthcare in the US each year, 22% is wasted on poorly coordinated care for the top 1% of these patients. These costs multiply across hospital systems.
The solution to our current "silo-based" model of care is a Collective Impact Initiative in Healthcare that seeks to improve health policy, health outcomes, and other social outcomes in Harris County, TX through two major innovations – (1) by overlapping information in a data infrastructure and (2) by fostering dynamic collaboration between stakeholders through a communications infrastructure.
A Data Infrastructure is needed to allow data sharing, identification of duplicated services and the problems experienced within those populations, and analytics across service delivery systems (of both health care and other services).
A Communications Infrastructure is needed to bring government leaders, service providers, and consumers together and organize input to enhance collaboration for developing solutions. The newly created Community Health Council (CHC) will implement this communications infrastructure.
How can I contribute and/or participate in the Council?
There are a variety of ways to support the Community Health Council – from becoming a partner, to contributing data, to contributing resources. Please get in touch with us to find out more information on how to participate.