The Primary Care Resource Center began at Conemaugh Health System in 2013 as a grant project through the Pittsburgh Regional Health Initiative with a focus on transitions of care for complex patients to reduce re-hospitalizations and the overall cost of care. The department has continued to evolve since its opening, and is now a standard department with the hospital. Our team consists of a group of pharmacists, nurses, population health specialists, and a data analyst that focus on improving the health and wellness of our community. Staff provide outreach to complex, high-risk patients with specific diagnoses to prevent readmissions. Further, the staff is an integral part of the clinically integrated network (CIN), Advantage Point Health Alliance – Laurel Highlands, and work with primary care providers to achieve the best quality care for patients, supporting the “Triple Aim” initiative to improve the experience of care, improve the health of the population, and reduce cost.
RN Case Managers provide outreach to complex, high-risk patients with specific diagnoses, with a primary goal of educating the patient on their disease state and treatment plan, as well as offer solutions to prevent readmission. These solutions range rom transportation assistance, facilitating appointments with their primary care provider or specialist, assist in placing patients in a higher level of care from home or the emergency department, and providing self-management equipment (e.g. scales, pill boxes, blood pressure cuffs) to patients in need.
Chronic Disease State Management
RN Case Managers and Pharmacist staff provide outreach to patients to provide education on their disease state and treatment plan, as well as lifestyle counseling, medication education, and medication adherence. Pharmacists will collaborate with primary care providers to offer patient specific support and medication review.
Post-Acute Provider Collaboration
Our staff works closely with post-acute facilities to ensure smooth transitions of care from hospital to post-acute care to home. Frequent touch points with post-acute providers aids in the effort to prevent readmissions and provide quality care to patients. Our department facilitates InterACT training with post-acute providers, which is a quality improvement program that focuses on reducing unnecessary admissions to the hospital.
Clinically Intergrated Network (CIN)
Our team works directly with the CIN by contributing to care coordination, chronic illness management, and preventative care. We work with primary care providers in the CIN to achieve the best quality for patients by addressing gaps in care, medication adjustments, patient advocacy, and health and wellness promotion. Additionally, we collaborate with insurance providers in order to achieve success in the CIN's various value based on reimbursement programs.
To learn more about Advantage Point Health Alliance - Laurel Highlands, visit here.
Kirsten Held, PharmD, BCPS
Marcia Slisz, RN, BSN, MHA
Kayla Thompson, RN
Keshia Peterson, RN
Sonia Walker, BN, BSN, PCCN
Amy Hall, LPN, Population Health Specialist
Nicole Chase, Data Analyst
Jessica Andersen, PharmD
Amy Rolley, Population Health Specialist
1086 Franklin Street, Good Samaritan Building, G650
Johnstown, PA 15905