PRIMARY CARE RESOURCE CENTER: STRENGTHENING CARE ...

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Through the Primary Care Resource Center (PCRC). Project, the Pittsburgh Regional Health Initiative (PRHI) equipped six
PRIMARY CARE RESOURCE CENTER: STRENGTHENING CARE TRANSITIONS, REDUCING HOSPITAL READMISSIONS FUNDER: CMS/CMMI | AWARD: JULY 2012 | DURATION: 3 YEARS | PRHI’S ROLE: LEAD GRANTEE Through the Primary Care Resource Center (PCRC) Project, the Pittsburgh Regional Health Initiative (PRHI) equipped six local community hospitals with the quality improvement, disease management, and motivational interviewing expertise to offer complex patients one-stop, coordinated outpatient care — while achieving both readmissions reductions and cost savings. The PCRC project, funded by a $10.4 million Center for Medicare and Medicaid Innovation (CMMI) grant, focused on patients with chronic obstructive pulmonary disease, acute myocardial infarctions, and/or heart failure at six community hospitals in western Pennsylvania and West Virginia: Butler Health System, Conemaugh Memorial Medical Center, Indiana Regional Medical Center, Monongahela Valley Hospital (the PCRC pilot site), Sharon Regional Health System, and Wheeling Hospital. PCRC teams — comprised of a nurse care manager, pharmacist, physician, administrative assistant, and other specialists — followed a six-step, “perfect discharge bundle” to prevent avoidable readmissions. PCRC staff met with a patient as soon as possible following a hospital admission, provided 30 minutes of bedside education, reviewed medications, created a discharge action plan, notified the patient’s primary care provider, and made a follow-up phone call within 72 hours of discharge. Leveraging its national partnerships, PRHI also facilitated advanced disease management training sessions for PCRC staff with the COPD Foundation as well as the American Heart Association. To further ensure care continuity for PCRC patients, PRHI helped foster connections between the community hospitals and post-acute care facilities, rehab and assisted living, personal care homes, and home health care services. Collectively, the PCRC sites achieved a 25% reduction in all-cause 30-day hospital readmissions for enrolled patients. The PCRCs also generated more than $1,000 in

post-acute care savings per patient during the first 90 days following discharge, compared to a control cohort. Recognizing the value and sustainability of the PCRC model, five of the six community hospitals have continued operating their PCRCs past the CMS/CMMI grant phase of the project.

PCRC ACCOMPLISHMENTS

25%

DECREASED 30-DAY READMISSIONS BY 25%

$ $1,000+ REDUCED 90-DAY TOTAL COSTS OF CARE BY $1,000+ PER PATIENT

8,947 51 PCRC STAFF WHO RECEIVED QI, DISEASE MANAGEMENT, AND MOTIVATIONAL INTERVIEWING TRAINING

UNIQUE PATIENTS ENROLLED IN PCRC CARE

14,279 HOSPITAL DISCHARGES MANAGED FOR PCRC PATIENTS

© Pittsburgh Regional Health Initiative 2016

40,541

FACE-TO-FACE CONTACTS WITH PATIENTS (CARE MANAGEMENT, MED REC, EDUCATION, ADVANCE DIRECTIVE PLANNING