@HealthValueHub

Patient Care Intervention Center

Texas

The Patient Care Intervention Center (PCIC) is a non-profit organization that's mission is to improve healthcare quality and lower costs for vulnerable citizens through data integration and care coordination. PCIC's Care Coordination program aims to lower emergency room visits and hospitalizations, lower total healthcare costs and improve quality of life for Harris County's high-utilizers using an interdisciplinary care team approach. Once identified, eligible patients meet with the care team and fill out a detailed questionnaire to help the team identify potential medical and social needs. The team then works with the patient to create a personalized care plan (spanning 2 to 6 months depending on the complexity of the patient's issues). During this time, the team conducts weekly home visits to discuss any problems and/or scheduled appointments. Team members may also accompany the patient to doctor's appointments or hospital visits.
Partner Organizations	Community Health Choice Houston Methodist Hospital
Target Population	Individuals with 10+ emergency room visits and/or 4+ admissions in the last year who have been diagnosed with at least two chronic conditions
Care Team	Social worker, paramedics, community health workers, physician
Timeframe	2013 - present
Results/ Studies	N/A
Funding	Private grant
Resources	Program website