Patient Care Intervention Center

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  • 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 Portal

    Unified Care Continuum Portal

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

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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 Loretha's life was transformed and more inspiring stories.

    Read more
  • Community Health Council

    Community Health Council

    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 through an innovative - Data and Communications infrastructure

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  • Patient Stories

    Strengthening the Health System in Texas

    - one life at a time.

    • Striving for change.
    • Engaging multi-sector agencies.
    • Sharing data.
    • Building communication.
    • Coordinating care plans.

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  • The Multiplier Effect

    The Multiplier Effect

    High-Need, High-Cost patients don't visit one hospital; they visit multiple. The top 53 super users of one system in Houston visited 36 different hospitals, costing at least $20.2M, in a single year.

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

Intervention

PCIC Intervention

PCIC's intensive case management and intervention program for High-Need, High-Cost patients in Harris county.

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Health Council

PCIC Health Council

A collaborative healthcare model comprised of a data and communications infrastructure.

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Data & Technology

PCIC Data and Technology

PCIC's data and technology platforms provide the framework for data-driven patient care.

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Research

PCIC Research and Development

PCIC's research platform provides a mechanism to rigorously evaluate our care coordination approaches.

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  • PCIC Patients
  • PCIC Patients
  • PCIC Patients
  • PCIC Patients
  • PCIC Patients
  • PCIC Patients
  • PCIC Patients
  • PCIC Patients
  • Mr. Lee

    Saving Lives

    Until early 2000, 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 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.

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  • 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.

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  • 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.

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87

clients enrolled

2531

hours of intervention

3499671

saved

51

% ER visits reduced

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
  • Elizabeth Bello

    The team at PCIC have provided essential design and implementation support as we created data tools to evaluate our clinical and operational work flow. They suggested appropriate modifications to our general operational metrics design to ensure scalability, reporting, and a useful platform for business analysis. The dashboards they created with our input are easy to navigate and display data analytics that are intuitive and conducive to discussion for our internal and external colleagues.

    Overall, PCIC has worked collaboratively with all of us as part of our team, as well as providing an important and objective consultant perspective. Their contributions allow us to improve our business and most importantly, enhance patient care.

    Elizabeth Bello Chief Quality Officer - JSA Health Telepsychiatry
  • 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

StreetEMR -

Referral Care Coordination UCCP Tracking

A cloud based, "light-weight" Electronic Medical Record system that is designed for patient care management and coordination.

It is built for ease of use, focusing on User Experience.

StreetEMR has features that enable easy use in a mobile environment using tablet devices like the Microsoft Surface Pro 3.

Other features include secure role-based access, a care plan development platform, a communications and referral platform, and interactive dashboards.


Learn more
StreetEMR

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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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