Primary Care Resource Centers

The Issue

Data shows that one in five elderly patients is readmitted to the hospital within 30 days of discharge. Some return trips are part of a treatment plan, some are unplanned but difficult to prevent, some can be prevented if patients are better prepared for discharge and if there is better support and coordination of care post-discharge. It is this last segment—avoidable readmissions—that is the focus of the Centers for Medicare and Medicaid (CMS) Hospital Readmission Reduction Program, and the focus of the Primary Care Resource Center project.

The Solution

In May 2012, the Pittsburgh Regional Health Initiative received a three-year $10.4 million award from the Center for Medicare and Medicaid Innovation (CMMI) to create a series of six hospital-based support hubs (Primary Care Resource Centers). These centers focus on effective care transitions of complex patients in order to assure they receive the level of care and support during and post discharge needed to reduce re-hospitalizations and the overall cost of care.

PHRI was one of 107 awards given to investigators across the country, from approximately 3,000 applications.

The Primary Care Resource Center (PCRC) cohort was selected in March 2013, and includes:

  • Butler Health System (Butler, PA)
  • Conemaugh Memorial Medical Center (Johnstown, PA)
  • Indiana Regional Medical Center (Indiana, PA)
  • Sharon Regional Health System (Sharon, PA)
  • Uniontown Hospital (Uniontown, PA)
  • Wheeling Hospital (Wheeling, WV)

Also included in the PCRC consortium is Monongahela Valley Hospital, the pilot site for the PCRC model (opened in July 2012). This pilot PCRC, which focused in year one only on patients with chronic obstructive pulmonary disease (COPD) was able to reduce COPD readmissions by more than 45% in the first six months as compared to the prior year.

Each PCRC in the CMMI grant is focusing on patient education and care coordination for patients with the three chronic diseases identified through data analysis as being at highest risk of avoidable readmissions within the PCRC hospital cohort: patients with COPD, heart failure (HF), and/or acute myocardial infarctions (AMI).

PRHI is providing funding, facilitation, quality improvement training and coaching, clinical expertise, and the coordination of best practices between PCRC hospital partners. With PRHI support, each PCRC was customized to reflect the hospital’s community and culture. Using Perfecting Patient CareSM methods, a multidisciplinary team was created at each hospital participating in the PCRC project to improve the care processes for COPD, HF and AMI. The team focused on the admission and discharge processes, as well as what happens after the patient is discharged.

By working together and aligning resources and goals of care, patients at risk for readmission can be kept healthier and out of the hospital. Participating hospitals had access to care pathways designed by experts and each team customized for their PCRC, with input from physicians and other members of the healthcare team.

Wheeling Hospital began enrolling patients and collecting data in July 2013. Butler Health System, Sharon Regional Health System, and Uniontown Hospital began enrolling patients and collecting data in August 2013; and Conemaugh Memorial Medical Center and Indiana Regional Medical Center began enrolling patients and collecting data in September 2013.

Each PCRC is staffed by three nurse care managers, a pharmacist, administrative support (paid for under the grant), and personnel from the hospital, including persons such as diabetes educators, nutritionists, social services, behavioral health services, respiratory therapy, and more. Patients admitted to the hospital for COPD, HF, or AMI are monitored by PCRC staff throughout their stay and receive education about their condition, medication review, self-management skills, and a home action plan constructed with their physicians’ input. The PCRC team members also make follow-up phone calls and conduct home visits to support home action plans constructed with physicians’ input.

The PCRC is not a replacement for the primary care physician, but provides a way for PCPs to share valuable resources for enhanced patient care. Although the movement towards hospital-owned primary care practice is growing, a majority of the primary care practices are still independent, physician-owned small and medium sized practices.

These small and medium sized practices are facing the same pressure to improve the capacity, quality, and value of the care they provide, yet they lack the financial and human capital to perform some of the activities required to do so, such as employing nurse care managers to assist patients who have chronic conditions. The PCRC model makes it possible for smaller practices to access/share resources to improve care.

The PCRC model is unique in that it is an patient education and care coordination model that is hospital-based. It provides a means for community hospitals with excess physical capacity to use that space for the benefit of their patients and their aligned physician practices.

Measure of Success

The principle clinical outcome goal of the PCRC project is to reduce all-cause 30-day readmission rates among patients with the target diseases by 40%, with estimated savings to Medicare of approximately $41 million. Over the three-year period, Pittsburgh Regional Health Initiative’s program will train an estimated 450 healthcare workers and create an estimated 26 new jobs. These workers will combine core competencies in the management of specific diseases with primary care support skills, and will be trained in evidence-based pathways of care.

Results to Date

The PRHI research team will analyze PCRC data at key milestones and results will be reported on this page.

Principal Investigator
Keith T. Kanel, MD
Chief Medical Officer, PRHI
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