Patient Care Intervention Center

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care coordination - Patient Care Intervention Center

Population Health

PCIC Population Health Initiative

PCIC population health efforts are focused on solving two deeply interconnected problems: the major inefficiencies in Houston’s fragmented and silo-based approach to healthcare; and the severe health problems, and associated costs, of marginal members of our community.

Our approach thus far has focused on implementing a successful care coordination intervention for High-Need, High-Cost patients of healthcare and we are expanding our experience with that population to offer a systematic mechanism to define problems, reduce duplication and cost, and design evidenced based interventions – the Community Health Council.

What is the problem?

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 patients 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.

In Harris County, there are 6,000 High-Need, High-Cost patients with costs exceeding $800M for Medicaid alone. Current mechanisms to improve care exist only within individual hospital systems despite the problem being poor care coordination across the many systems. For example, if the top 53 High-Need, High-Cost patients identified in one hospital system obtained care at 36 different hospitals throughout the county, they cost a single hospital system $8.6M, with the cost to the entire health system projected at $20.2M.

High-Need, High-Cost patients of the health care system are especially costly and many efforts are targeting this population nationally. However, there are many different populations of "High-Need, High-Cost" patients of government (and non-government) services, involving multiple overlapping systems. For example, mentally ill homeless individuals have multiple interactions with various government services, including jails, shelters, and emergency rooms. “Super-truants” – students who are excessively absent from school – overlap multiple systems as children and adolescents and may later become High-Need, High-Cost patients of healthcare. Substance abusers, especially “kush” users in Houston, also utilize multiple services chaotically and inefficiently, revolving between incarceration, homelessness, hospitalization, and detox centers. Identifying populations that appear in multiple systems can uncover problems that may not be especially costly or problematic for any single system but are very problematic for the system as a whole.

In this section, you will find information on both our approach to the High-Need, High-Cost population as well as our proposed mechanism – the Community Health Council – for addressing broader overlapping populations.

Referral System

PCIC analyses large datasets to identify High-Need, High-Cost (HNHC) patients of a system. This is done at the individual institution level or across multiple institutions through an overlap analysis. Additional information on PCIC's data analysis can be found here.

In addition to identifying and enrolling patients through data analysis, PCIC also has a referral program that enables our stakeholder and partner institutions to refer clients to PCIC through the referral program. Clients are required to meet the same criteria to be enrolled into the intervention program through a referral (i.e. 4+ hospital admissions per year, or 10+ ER visits per year, and 2+ chronic conditions).

On graduation, there is a warm handoff to the referring organization or the primary care physician of the client.

Referral Workflow
Most hospital systems in Houston and Harris County have their own frequenters program that usually deal with a large number of patients. PCIC is building relationships with these programs with a goal to create a true safety-net across systems. With over 6000 HNHC patients in Houston alone, it is impossible for any one program to provide care coordination services to this population. Our goal at PCIC is not to increase capacity but to connect the programs, and stratify the HNHC population by intensity of case management required. Programs like the HHS frequenters program work closely with PCIC in analyzing clients from both our HNHC patients lists, and handing off clients requiring high intensity case management to PCIC. Once we complete our intervention we hand the client back to the HHS program. This kind of a connected safety-net prevents clients being dropped off the program without a clear follow up plan.

Referral System

PCIC is working on a referral system that is integrated into its Electronic Medical Record system to streamline the referral workflow. This will enable for easy handoff of clients between a stakeholder and PCIC as well as provide a secure communication and collaboration platform between organizations. Additional information on PCIC's referral system can be found here.

StreetEMR - Referral

PCIC analyses large datasets to identify super users of a system. This is done at the individual institution level or across multiple institutions through an overlap analysis. Additional information on PCIC's data analysis can be found here.

In addition to identifying and enrolling patients through data analysis, PCIC also has a referral program that enables our stakeholder and partner institutions to refer clients to PCIC through the referral program. Clients are required to meet the same criteria to be enrolled into the intervention program through a referral (i.e. 4+ hospital admissions per year, or 10+ ER visits per year, and 2+ chronic conditions).

Referral System

PCIC is working on a referral system that is integrated into StreetEMR to streamline the referral workflow. This will enable for easy handoff of clients between a stakeholder and PCIC as well as provide a secure communication and collaboration platform between organizations.


Referral system's four main functional areas

Referral Portal

The referral portal is the entry point into the referral system and provides the mechanism for stakeholders and partner organizations to refer a patient to PCIC for care coordination. It provides an environment to collect the needed data points required for a referral as well as provide dashboards to track the progress and workflow.

Selection Portal

The selection portal handles all steps involved in the selection process of a client. This includes forms required to be filled out, managing triage criteria and selection criteria, interview with clients and the review of medical history.

Referral Workflow Management

The entire workflow and routing of information is managed through the referral workflow management system. This involves all business rules and logic that are defined in the system that determine how a referral is handled in the system.

Communication Platform

The communication platform handles all secure communication that the system sends out to users involved in the referral process. These communications mechanisms are designed to notify users using a variety of media – from secure mail, to secure messaging to voice calls.
Referral Workflow

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Our Vision

At PCIC we envision a coordinated health safety-net where all stakeholders share data to make better decisions.

Our Mission

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

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