Patient Care Intervention Center

care coordination - Patient Care Intervention Center

Population Health

Written by Administrator PCIC on .

Our work revolves around innovating ways for communities to measure, track, and improve the health of their most vulnerable populations.

We focus specifically on improving health outcomes for the most frequent users of emergency medical and social services, who often incur the highest healthcare costs.

Because most health outcomes are determined by social, environmental and behavioral factors – many of which fall outside of the traditional medical domain – efforts to improve healthcare systems must span the entire continuum of care.

Social Determinants of Health

At PCIC, we employ systems-level thinking to meaningfully measure and address social, behavioral, and environmental determinants of health.


Learn more about our approach

Research

How do we know our work delivers value to our customers and adds meaningful impact to the communities we serve?

We have built standardized measures of success into all aspects of our practice, from care coordination to product development and data analysis. Our internal research division collaborates with community stakeholders to drive rigorous evaluations that inform our service delivery.


Learn more about our research

Referral System

Written by Administrator PCIC on .

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

Written by Administrator PCIC on .

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 Mission

Humanize health equity by integrating clinical, behavioral, and social determinants of health into serviceable insights that our partners use to drive action, putting each individual on a path toward achievable health and well-being.

We Envision

Creating a new reality of integrated effective care that will transform the lives of all people, especially vulnerable populations – a beacon for True Health Equity.

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