Patient Care Intervention Center

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Design and Framework of a Technology-Based Closed-Loop Referral Project for Care Coordination of Social Determinants of Health

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PCIC CEO Kallol Mahata co-authored a new publication in Population Health Management, "Design and Framework of a Technology-Based Closed-Loop Referral Project for Care Coordination of Social Determinants of Health."

Screening for social determinants of health (SDOH) has been mandated by health systems nationwide. However, a gap exists in closed-loop referral for care coordination between health care and social services. This article presents the framework of a technology-based project to facilitate closed-loop referral between health care and social service agencies in Greater Houston by leveraging and connecting the existing care coordination technology infrastructure. Ten health care and social service organizations in Greater Houston participated in the demonstration project initiated in January 2023. The authors leveraged and linked regional health information exchange (HIE) technology with a master patient index of >18 million, and sector-specific care coordination platforms to build closed-loop referral capacity between HIE-participating health care organizations and social service organizations to meet patient SDOH needs. Evaluation efforts will assess the reach, adoption, implementation, and the effectiveness of the closed-loop framework in improving social and health outcomes. Read Article
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Hurricane Preparedness Tips: Essential Steps for Staying Safe

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As a nonprofit committed to leveraging health data and technology to improve patient outcomes, the Patient Care Intervention Center (PCIC) team understands the importance of being prepared for emergencies. In Texas and other coastal regions, hurricane season can disrupt not only daily routines but also critical health services, making preparation crucial for individuals, families, and healthcare providers alike.

To help you stay safe and ready, we’ve compiled a list of essential hurricane preparedness tips to protect your loved ones and ensure that you’re ready when a storm threatens.

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Reimagining Care for Vulnerable Populations: A Retrospective on the PCIC and Amerigroup Partnership

“We want to make an impact, but we don’t know if we’re helping the people who need it most, and we have a hard time tracking the long-term impact of our outreach team’s interventions.” Sound familiar?

PCIC can help—for example, our data-driven interventions in partnership with Amerigroup in 2023 led to a 75% reduction in hospital visits, a 72% decrease in healthcare costs, and a reported 12% improvement in quality of life for the enrolled patients.

These outcomes highlight PCIC’s ability to act as not just a partner, but an extension of our partners' teams, enabling you to maximize your resources with proven strategies that make a tangible impact.
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Private In-equity: Whose Interests Do We Serve?

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PCIC co-founder Dr. David Buck, in collaboration with Haaris Mateen, Assistant Professor of Finance at University of Houston Bauer College of Business, published an article in The Medical Care Blog breaking down the root causes of health inequity in the United States and suggesting a path forward for health and social care that supports vulnerable populations to not only survive, but thrive.

The pharmaceutical industry is a behemoth in the United States. In 2023, the 20 largest pharmaceutical companies had a market capitalization of $3.78 trillion dollars. Pharma companies spent more than $15 million dollars in contributions through political action commuttees during the 2020 election cycle. Analysts constantly see new avenues of generationg revenues and profits for the industry including, most recently, obesity drugs which are predicted to become a $44 billion market by 2030, according to Bloomberg Intelligence. Private equity has targeted elder and primary care for a quick investment return leaving long-term in-equities with significant public and health policy implications. Read Article
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Health & Homelessness in Houston: PCIC Partners with Dr. Ben King of UHCOM to Understand Harris County Homelessness Mortality

Mortality rates are increasing for people experiencing homelessness in Harris County, and we need to learn more about why and how to help.

Patient Care Intervention Center (PCIC) is partnering with Dr. Ben King of the University of Houston Tilman J. Fertitta Family College of Medicine (UHCOM) to understand trends in mortality rates and causes of death among people experiencing homelessness in Harris County.
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Breaking Down Nutrition Barriers: PCIC and UHCOM Partner to Improve Access to SNAP in Houston’s Third Ward

Healthy meals make a huge impact. In fact, poor nutrition is the main cause of poor health, high healthcare costs, and lower productivity in the US and globally. It leads to health issues like heart disease, cancer, and other serious conditions (Source: American Heart Association).

That’s why Patient Care Intervention Center (PCIC) is partnering with the University of Houston Tilman J. Fertitta Family College of Medicine (UHCOM) in 2024 to break down barriers to nutrition in the Houston Area by improving access to Supplemental Nutrition Assistance Program (SNAP) in Houston’s Third Ward.
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Advancing integrated care for individuals experiencing homelessness: harnessing data partnerships and coordination

PCIC co-founder, Dr. David Buck, in collaboration with experts from UH College of Medicine and Baylor College of Medicine, has published research on methods to advance integrated care for individuals experiencing homelessness, highlighting PCIC's efforts in scalable care coordination and data sharing mechanisms.

Bridging gaps in care coordination for homeless populations is a complex task that requires addressing attitudinal and behavioral changes, as patients hold more control over chronic and preventive care. Despite these challenges, organizations like the Patient Care Intervention Center (PCIC) have made significant strides in improving health equity for vulnerable populations in Houston. Read Article
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Lone Star Justice Alliance and PCIC: Pioneering an Alternative Method of Managing Reformative and Health-Related Practices Among Youths

PCIC has partnered with Lone Star Justice Alliance (LSJA), a nonprofit legal organization whose mission is to improve the lives of emerging adults (18-24 years old) in the justice system through utilization of developmentally appropriate responses to behavior, treating emerging adults with equity and dignity to promote resilience, conserve costs, and increase public safety. PCIC will provide a platform to support their “Transformative Justice” and “End Juvenile Life Sentences” programs, which implement innovative strategies for maximizing the supports and services needed to keep emerging adults in the community where their needs are better met at a lower cost to the state. Through targeted outreach, public awareness campaigns, and other organizing activities, LSJA’s community programs engage emerging adults and their families to promote the development of positive outcomes among Texas emerging adults.

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PCIC, Humana and the University of Houston CHW Join Forces to Inspire Change

In May 2020, leadership from PCIC, Humana and the University of Houston Community Health Worker Initiative (UH CHWI) presented an innovative, collaborative model of care at the virtual Collective Impact Forum. In the presentation, Tray Cockerell (Humana), Kallol Mahata (PCIC), and Dona Stelzig (UH CHW) spoke about their project’s goals and their organizations’ shared vision for revitalizing healthcare systems and combating current barriers to quality treatment.

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Presenting the Values-Based Model of Care to Healthcare Professionals from Around the World

PCIC’s board chair, Dr. David Buck, along with Dr. Stephanie Barker and Dr. Nick Maguire from the University of Southampton (a partner of PCIC), presented the “Values-Based Engagement in Healthcare” to an audience of international healthcare professionals at the fifteenth annual Street Medicine Institute Symposium, in Pittsburg, PA.

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A better approach to referrals

Patients with complex needs often require services from a variety of social, medical and government benefit agencies. While there are some systems in place to coordinate referrals between providers, some key issues remain.

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Using Systems Dynamics to understand PCIC’s competitive advantage: An interview with Homa Koohi

Homa Koohi, B.Sc in EE, MBA, is a MPA/ID candidate at Harvard Kennedy School of Government and a current intern of IMAGO Global Grassroots.

Homa spent her summer collaborating with PCIC to develop structured models to inform PCIC’s strategic decision making in the upcoming year.

We interviewed her to share the scope and application of her work. She hopes to continue working with PCIC as part of her capstone project for the Kennedy School.

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PCIC - Past and Present

The PCIC technology division has grown from humble beginnings – from a small home office in our co-founder's house to a fully functional technology, media and data management initiative, spanning both our Dallas and Houston offices.

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How stepping out of my comfort zone gives me new perspective as a data analyst

"Why do you find your work at PCIC exceptionally rewarding?"

This great question was posed to me by several different candidates whom I was interviewing for a new data analyst position at PCIC. While my immediate answer was honest and concise – that I enjoy problem solving, developing databases, and creating innovative data solutions – I didn’t feel that it fully encapsulated what makes PCIC a special place to work.

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What is the real cost of chronic illness?

Over the last several decades, healthcare improvement efforts have focused on improving health outcomes while reducing healthcare costs. One patient population in particular garners much attention in these efforts: High-Need, High-Cost (HNHC) patients. HNHC patients are often identified by a frequently cited statistic – 5% of the U.S. population who generates 50% of annual healthcare spending.

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PCIC is Part of a National Movement to Change Healthcare

Our data analyst recently attended the Putting Care at the Center Conference in Los Angeles, CA. She presented a poster about PCIC’s interventions with High-Need, High-Cost patients, and discussed the importance of values-based care with fellow participants. Below are takeaways from our interview with her after she returned.

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The role of machine learning in effective and efficient care coordination

The role of machine learning in effective and efficient care coordination

We see machine learning applied in a lot of business these days, from optimal search engine results to shopping recommendations. When IBM Watson won “Jeopardy!” against humans, it marked the beginning of a new era in artificial intelligence, where machines don’t just pull answers from a vast set of available resources but can analyze and process the information within a really short period of time. The healthcare industry is no stranger to machine learning. For example, Google’s machine learning algorithm is now detecting breast cancer with an 89% accuracy, when compared to 73% for a pathologist.

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Medicaid: Key to Healthy Communities

As a care coordinator, my daily conversations with clients usually revolve around care management – following up on clinic referrals, medication management, disease management education, etc. However, many of our recent conversations have centered on their anxieties about the future of Medicaid. Some of our clients are so anxious that even the simple act of watching news coverage about Medicaid reform can incite a panic attack.

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Another explanation for frequent ER visits: Somatic Complaints

Most PCIC clients have lived through traumatic experiences or are burdened with stressful situations and environments. Add these factors to their multiple complex illnesses. Unfortunately, some mental illnesses are better addressed outside of the Emergency Room. We teach our clients to recognize the importance of mental health and how it can affect physical well-being, and we encourage them to seek help if needed.

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Securing Computer Systems: 3 Ways to Authenticate your Systems

Computer security is the act of protecting computer systems from theft or damage to hardware, software or information, and disruption or misdirection of their services. Many systems are under constant threat of hacking, ranging from individual mobile phones to large establishments. In this post, we will focus on one of the methods used to protect sensitive data – Authentication.

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Breaking Barriers: A glimpse of the DevOps culture at PCIC

What is DevOps? It's what started as a buzzword and quickly transformed into a movement. DevOps is the union of development and operation teams at every step of the work cycle. DevOps originated as a means to break down walls that hinder production. Previously, software development teams would work separate from operations teams. This allowed for issues with long deployment cycles and inflexibility. Now with the merge of development and operations, it has evolved into a culture promoting collaboration and autonomy.

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Beyond the Diagnosis

Imagine being so sick that you visit the emergency room at least ten times or are admitted to a hospital at least four times within a single year. This extreme utilization, combined with at least two chronic health conditions, meets the eligibility requirements for PCIC’s intensive case management program. However, many of our clients far exceed these requirements.

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User experience (UX) driven technology development in care coordination

Back in 2004, I started working on a project to build the first web based electronic medical record system in the country, with Jim Turley, RN, PhD – an amazing bioinformatics expert and Dr. Buck (David) – who was then the President at HealthCare for the Homeless - Houston. This was part of my graduate school thesis work, trying to figure out workflow models and data entry flows that worked best for street outreach.

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Welcoming our newest PCIC care coordinator!

Dear Friends and Supporters of PCIC:

We'd like to welcome our newest PCIC care coordinator, Chris Dammel. Chris is a firefighter with the Houston Fire Department, and has served his community for ten years. He heard about PCIC from current care coordinators, Eric Lobpries and Karen Dupont. Although he's only been with us for a month, he has some great insight about our organization's vision and goals with the clients.

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PCIC Updates - Phase 1 Conclusion

Dear friends and supporters of PCIC:

We wanted to share with you our news as we conclude Phase I. The project is moving into Phase II thanks to YOU, our collaborators, stakeholders and funders.

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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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