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Provider Stories: Patient-Provider Power Struggle

David Buck, M.D., M.P.H., has agreed to share his own experiences with complex patients. This specific story highlights the importance of doctor-patient interaction when caring for complex patients. Welcome to our newest segment:

Provider Stories: Patient-Provider Power Struggle


Using Technology to Transform Health Care in Houston

Published On: September 13 2017 in National Center for Complex Health and Social Needs. This is an interview with Kallol Mahata. Read the article here.

At the heart of complex care is identification: Where and how do we find the most vulnerable patients? When our team started studying individuals in Houston who tend to overuse emergency department and inpatient visits, we realized our community was siloed in its approaches.


Ms. Charlott: Before, During, and After PCIC

Ms. Charlott has made significant improvements in managing her health since being featured as our June Human of Healthcare.

Before enlisting the help of PCIC, she found herself being shuffled around multiple doctors to find a diagnosis. The lack of communication between providers only caused her to start losing energy and hope of ever recovering from her illnesses. If it were not for her dedication to getting better, her support system made of family and PCIC, and her faith, she would have given in to her illness.


Mr. Trondail: From Day 1 to Graduation

"When I came into this program it was like, really, really, how can I say this, at a time I needed support. My closest family member is 1,500 miles away. I was going through something, and the next thing I know, these wonderful people show up on my doorstep, and it was like they were basically more than just a support group for me to gain and get my health together. They have been there for me, when I say, they have shared good positive tears, tears of joy…they have been there for me. I really appreciate it… This is what the outcome has been for me so far, and I know it’s going to get a lot better." says Trondail.


Caring for High Need, High Cost Patients

Podcast published on: March 2017 in Review of Systems. Listen to the complete interview here.

Dr. David Buck of Patient Care Intervention Center and Baylor College of Medicine Houston talks with Thomas Kim about caring for superutilizers - high need, high cost patients.


Social Interventions Can Lower Costs and Improve Outcomes

Published On: March 2017 in NEJM Catalyst. This article is by David S. Buck, MD, MPH & R. Conor Holton-Burke, MS. Read the story here. Available on Patient Engagement as well.

It was a hot and humid day in Houston — the oppressive sort that makes one contemplate retreating to air conditioning immediately after stepping outside. Our patients did not have that luxury.


Breaking Boundaries - Health systems are evolving and advancing their strategies to address social determinants of health

Published On: February 2017 in Deloitte Center for Health Solutions. Read the story here.

More than a decade ago, family physician Jeffrey Brenner, inspired by police department strategies to map crime data to identify "hot spots," began to use ambulance records and emergency department (ED) data to predict and aim to address health care hot spots.


Tackling Patients' Social Problems Can Cut Health Costs

Published On: January 2017 in Kaiser Health News. Read the story here. This KHN story also ran on PBS NewsHour.

HOUSTON — Donning a protective gown, rubber gloves and a face mask, Dayna Gurley looks like she's heading into surgery. But Gurley is a medical social worker charged with figuring out why her client, a man who uses more health care services than almost anyone else in Houston, has been in three different hospitals in the last month.

The patient, who asked not to be identified, has chronic massive ulcers, AIDS and auditory hallucinations. He rents a cot in another person's home but is more often homeless, with no family to help him.


"A way to save money when half of all health costs is spent on a fraction of patients" - PBS NewsHour

Published On: January 2017 in PBS NewsHour. Read the story here.

Health care "super-utilizers" make up just 5 percent of the U.S. population but they account for 50 percent of health care spending. As health care costs continue to rise, providers are trying to figure out how to find these patients and get to the root of their problems. But the looming repeal of the Affordable Care Act may disrupt those efforts.


Strengthening the health system in Texas

Mr. Timmy

Published On: December 2016 in Episcopal Health Foundation. Read the story here.

He was sitting in his old wheelchair with his phone in his hand. He was grey, had difficulty breathing and was very confused. We immediately called 911.

Timmy was on the outside of the health system looking in. And it almost cost him his life.


Camden health-care coalition gets grant for national program

The Camden Coalition of Healthcare Providers, led by MacArthur Fellow and primary-care physician Jeffrey Brenner, has won renown for its efforts to address the complex needs of Camden's sickest residents.

Now, on the heels of establishing the National Center for Complex Health & Social Needs this year, the Camden Coalition has won a grant of up to $1.65 million over three years from Aetna Foundation to develop a curriculum that will help other cities adopt the data-driven approach Brenner has used in Camden.


Repeat ER patients costing millions

Houston-area emergency rooms are packed and the taxpayer price tag is climbing. But one doctor's idea could not only shorten ER waits and save money, but could dramatically improve the health of Houston's most vulnerable patients...

Read the complete article on the ClickToHouston here.

Published On: Jun 17 2014 in KPRC.


Reduced ER trips

Houston health innovation center reduces ER trips

A new program of identifying patients who most frequently go to Houston-area emergency rooms and then coordinating their medical care has reduced ER visits by 85% in just three months, according to preliminary findings released today by the Primary Care Innovation Center (PCIC).

PCIC research is based on patients identified as "superutilizers" – patients who use emergency rooms across Houston more than 10 times in one year. During the three months before the PCIC program, eight of those patients visited an ER a total of 65 times.


Extreme Users

High utilization by intensive users

Intensive users of medical services account for 21% of the Medicaid budget in Texas. Four patients used emergency rooms at 19 different Houston hospitals a total of 179 times last year, according to Primary Care Innovation Center, a Houston nonprofit. One patient had a total of 56 visits to 10 different emergency rooms. These intensive users of medical services - in the jargon, "super-utilizers" - account for 21 percent of the Medicaid budget in Texas, according to Primary Care Innovation Center.


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

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

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