Primary Care Resource Centers


Phase I (demonstration project)

With data from the Pennsylvania Health Care Cost Containment Council, PRHI identified COPD as a high-impact readmission reduction opportunity and collaborated with a team at one local hospital on a demonstration project. Any patient admitted to the hospital with a primary or secondary diagnosis of COPD could participate in the project. The team included pulmonary and family practice primary care physicians, representatives from nursing, quality, pharmacy, respiratory, physical and occupational therapies, dietary, care management, home care, emergency, nursing education, and IT.

Using PRHI's Perfecting Patient CareSM Lean methodology for health care, the inpatient team observed the current condition and concluded:

• readmitted COPD patients were not taking their inhaler medications
• there was ineffective and inconsistent inhaler training for the patients
• a critical opportunity for reducing readmissions occurred shortly after a hospital discharge
A new protocol was instituted:
• inhaler training and smoking cessation education was now the responsibility of the respiratory department, instead of nursing
• the inpatient-outpatient team then made improvements to the system of patient care that bridged both hospital and community. A care manager was hired and met with patients while they were hospitalized, and followed up with home visits at which inhaler training was reinforced, education on patient care plans reviewed, and other needs assessed.
Additionally, the inpatient-outpatient team corrected the following processes for patients with COPD:
• methods for identifying readmissions and determining how inpatient care should change
• guidelines for care of patients during their stay and post-discharge, as well as mechanisms for monitoring deviations
• methods for training physicians and staff on guidelines and processes
• mechanisms for preparing a patient for discharge

One year after the new protocol was rolled out, this hospital saw a 44% reduction (payer net savings of $217,000) in patients admitted for COPD exacerbation and readmitted within 30 days for COPD or pneumonia.

Phase II - Primary Care Resource Center (prototype)

About one in five patients at local community hospitals were being readmitted to the hospital within 30 days after discharge. When PRHI looked at the numbers for some of the diseases with the highest 30-day readmission rates – chronic obstructive pulmonary disease, acute myocardial infarction, and heart failure – the data were astounding.

Building on the success of the demonstration project, PRHI, with a pilot grant from Highmark, collaborated with a 210-bed, full-service community hospital to open the first Primary Care Resource Center (PCRC) - a dedicated space in the hospital for centralized, coordinated care for patients with COPD, CHF, or CAD. With PRHI's Perfecting Patient CareSMLean methodology providing the foundation, the Monongahela Valley Hospital PCRC opened July 2012. They implemented the best practices from Phase I, and supplemented their three nurse care managers with a clinical pharmacist dedicated to the team. The hospital covered the cost of the pharmacist. The idea was to introduce hospitalized patients to a nurse and a pharmacist who would follow up with them after they left the hospital – not just by phone, but in person in the home if needed. The contact would continue for at least 30 days. Monongahela Valley Hospital developed care paths, physician outreach strategies, and data collection tools that led to a 45% reduction in readmissions, and provided a blueprint for Phase III.

Phase III - Primary Care Resource Centers

The Centers for Medicare and Medicaid Services’ Innovation Center provided a testing ground for new, disruptive service delivery and payment models. Through an ultra-competitive process, organizations were chosen to translate their concepts to the front lines of care in the name of better population health and lower costs. The initial data from Phase II was strong enough to persuade the Centers for Medicaid and Medicare Services Innovation Center to award the Pittsburgh Regional Health Initiative $10.4 million in 2013 to expand the concept to six community hospitals in the region for two years:

• Butler Memorial Hospital
• Conemaugh Memorial Medical Center
• Indiana Regional Medical Center
• Sharon Regional Medical Center
• Wheeling Hospital
• Uniontown Hospital

Everyone taking part in the PCRC project received PRHI's Perfecting Patient CareSM Lean training, as well as advanced disease management expertise to offer complex patients one-stop, coordinated outpatient care. PRHI applied design thinking to make care pathways and procedures sustainable for participating hospitals, and helped the staffs examine their own work flow and craft more efficient, durable procedures.

At each location, the hospital tweaked the format to address its patients’ needs – creating ideas for the other hospitals to add. The PCRC project’s innovations are numerous:

• better patient education
• to careful discharge planning
• to better care transitions
• embedding a pharmacist on the care team
• by leveraging community resources to support patients post-discharge
• preparing the teams with ongoing training in quality improvement, advanced disease management, best practices in discharge planning, patient motivational interviewing, as well as information sessions on palliative and end-of-life care

During the CMMI grant phase of the project (Fall of 2013 to Fall of 2015), the PCRCs collectively achieved a 25% reduction in 30-day hospital readmissions, and reduced the 90-day total costs of care by more than $1,000 per Medicare patient, compared to a control cohort analyzed by PRHI. While the grant phase of the project has ended, five of the six participating community hospitals have decided to self-fund their PCRCs.