Part of Pittsburgh Regional Health Initiative Project aimed at keeping patients healthy after discharge.
Conemaugh Memorial Medical Center held a grand opening reception for their new Primary Care Resource Center (PCRC), located on the ground floor of Conemaugh Memorial Medical Center.
The PCRC will serve as an extension of primary care practices, improving the transitions of care from the hospital to outpatient care for target patient populations at risk for high readmissions (patients with chronic obstructive pulmonary disease, heart failure, and acute myocardial infarctions), ensuring they continue to receive proper medical care and other services they need in order to keep them from returning to the hospital.
The Pittsburgh Regional Health Initiative (PRHI) received a Health Care Innovations Award, a three-year CMS Center for Medicare and Medicaid Innovation (CMMI) cooperative agreement, to create a series of six hospital-based support hubs (Primary Care Resource Centers) that focus on effective care transitions of complex patients in order to assure patients receive the level of care and support during and post discharge needed to reduce re-hospitalizations and the overall cost of care. PRHI estimates an approximate $41 million savings to Medicare alone over the three years of the grant, for the six hospital cohort.
Conemaugh Memorial Medical Center is one of the community hospitals recruited by PRHI to participate in the PCRC project.
“The Primary Care Resource Center model being implemented under this Award will give the six PCRC community hospitals—and by extension the primary care physicians taking care of PCRC patients— the resources to keep people healthy after discharge,” says Keith Kanel, MD, PRHI chief medical officer and the principal investigator for the CMMI PCRC project. “Many patients are discharged without understanding their illnesses or treatment plans. Hospital-based and community-based primary care physicians may not always communicate with each other to develop a coordinated post-discharge care plan for patients. Patients might not have the right prescriptions or be able to fill them, or they may take the wrong doses. They may forget to make their follow-up appointments with their primary care physician.
“There are so many places where problems that can be prevented are missed, leading to emergency room visits and unplanned readmissions. These issues are not unique to Conemaugh Memorial Medical Center: they are well-documented in numerous studies.”
Located on the ground floor of Conemaugh Memorial’s Good Samaritan building, the PCRC model implemented at Conemaugh Memorial Medical Center has been customized to reflect the hospital’s community and culture. 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, Conemaugh Memorial Medical Center developed their own pathways and protocols for a high-performing PCRC.
The 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 therapists and more. Patients admitted to the hospital for chronic obstructive pulmonary disease (COPD), heart failure, or acute myocardial infarction (AMI) will be 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 will also make follow-up phone calls and conduct home visits to support the home action plan.
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.
“We are very excited about this new program and the potential it has to impact the long term health of our patients,” says Dana Begley, Vice President of Medical Management and Post Acute Services at Conemaugh Memorial. “This program focuses on patient education and helping patients understand their disease and how to manage it. This is a great tool to empower patients and help improve their health.”
About Conemaugh Memorial Medical Center
Conemaugh Memorial Medical Center (MMC), the flagship hospital of the Conemaugh Health System is a regional referral hospital known for clinical excellence. Memorial has received HealthGrades Distinguished Hospital for Clinical Excellence award for 2012, 2011, 2009, 2008 and 2007, for clinical outcomes which are among the Top 5% in the nation. Conemaugh Memorial’s Regional Resource Trauma Center is one of only 11 Level One Trauma Centers in Pennsylvania and the only Level One Trauma Center between Pittsburgh and Hershey. Conemaugh Health System (CHS) is the largest healthcare provider in West Central Pennsylvania with 4,500+ employees and 350 physicians. Learn more at www.conemaugh.org
About the Pittsburgh Regional Health Initiative
The Pittsburgh Regional Health Initiative (PRHI) is an independent catalyst for improving healthcare safety and quality. It operates on the premise that dramatic quality improvement is the best cost-containment strategy for health care. PRHI is the first regional consortium of medical, business, and civic leaders to address healthcare safety and quality improvement as a social and business imperative. Turning its own community into a demonstration lab, PRHI strives to accelerate healthcare quality improvement and set the pace for the nation. PRHI believes that health care is local so Federal policy changes alone cannot achieve needed reform; those who work at the point of care develop quality and safety improvements that work and last. PRHI also believes that continuous improvement in quality and safety requires setting the highest possible standards, to settle for less limits achievement. For more information, visit www.prhi.org.
The project described was supported by Funding Opportunity Number CMS-1C1-12-0001 from the Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation. The contents of this document are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.
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