Patient Care Intervention Center

Location: Harris County
Amount: $875,000

Grant supports PCIC's systems change initiative to develop the infrastructure and legal agreements to build a platform for data sharing and analytics across systems and the creation of the Community Health Council to oversee data-based decision making at the community level.

How EHF and PCIC are working to strengthen the health system in Texas

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"He was sitting in his old wheelchair with his phone in his hand. He was grey, had difficulty breathing and was very confused. We immediately called 911."

Timmy Williams was on the outside of the health system looking in. And it almost cost him his life.

Timmy is a single father living in Houston. He's HIV-positive and lives with amputated legs. But in the years before his health was spiraling downward, the only healthcare he received was when he was so sick he had to be rushed to the emergency room. Timmy lived near the largest medical center in the world, but when it came to getting access to a system that could help him care for serious, chronic health conditions, Timmy didn't know where to turn.

"You know if they hadn't stepped in, I don't know what would have happened," Timmy said.

An intervention team from the Patient Care Intervention Center (PCIC) found Timmy close to death right at his front door. The team had identified him as "super-utilizer" -- a patient who went to emergency rooms in Houston more than 10 times in one year. In Harris County, there were more than 6,000 “super-utilizers” in 2013 alone.

The PCIC team followed Timmy to the hospital. They monitored his daily progress and after he was released, the team made visits to his apartment to coordinate all aspects of his healthcare. They connected him with a primary care physician, helped him get access to needed medications, secured home health providers, and even went along to doctor's appointments.

Timmy was now part of a new health system that provided him with invaluable, intensive, preventive care. This new coordinated system through PCIC addressed the underlying causes of his health problems, long before the symptoms became severe.

"Why is it that we can easily dismiss sick people and not care for them," said Dr. David Buck, founder and president of PCIC. "Our health system is badly broken. It's widely expensive with some of the poorest outcomes. PCIC works to systematically provide the most vulnerable people with more access to a more effective kind of care."

EHF supports PCIC with both funding and collaboration. It's just one way we're working with nonprofits, health departments, people of faith, philanthropic institutions and community members to create a system that ensures Texans not only receive quality medical care, but that the places they live and work enable them to get and stay healthy.

"EHF doesn't look at itself as a funder," Buck says. "The foundation looks at itself as a way to begin to change the system."

Through grants, research, community engagement and partnerships with Episcopal churches, EHF is helping transform communities by making long-lasting improvements to the systems that shape and influence the health of our residents.

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"I would say I came a long way from where I was," Timmy said.

Timmy is now much happier and healthier. He's able to watch his young son grow up. He's connected to a system of health that helps him successfully manage his medical conditions, not just react to symptoms when they become severe.

Addressing critical needs for Texans like Timmy is why EHF was created. He's one reason we’re working so hard to focus on new and different ways to improve population health by changing the way health systems work for those most in need.


PCIC's Story

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Dr. David Buck, president of the Patient Care Innovation Center, meets with a program patient.

Houston Fire Department paramedics knew Mr. B’s home in Houston all too well. In just seven months, Mr. B or his mom had made 22 calls to 911. The 42-year-old was frail, his eyes were sunken and his skin was a terrible shade of grey. For several months, Mr. B’s mom had tried to keep his weight up by feeding him beans, but he kept getting sick. Since he didn’t have a doctor, they called 911 for an ambulance ride to the emergency room.

“Without a primary care physician, Mr. B had no direction on how to improve his health,” said Dr. David Buck, a professor of family medicine at Baylor College of Medicine. “The ER was his only source of medical care.”

Mr. B is part of a small, but extremely-costly group known as “frequent flyers” or “super-utilizers” – patients who have visited the emergency room at least 10 times in one year. In Harris County, there were more than 6,000 “super-utilizers” in 2013.

“They’re the costliest and most vulnerable patients, yet they’re not getting the care they need,” said Buck. “The U.S. spends $2.8 trillion dollars on health care, half of that amount ($1.4 trillion) is spent on patient's like Mr. B who account for just 5% of the general population.” 

That’s why Buck founded the Patient Care Innovation Center (PCIC) in 2014. The group’s goal is to identify a group of super-utilizers, get to know their stories and then coordinate their health care. The PCIC team includes HFD firefighters, case workers and nurses. Each week, team members coordinate each patient's chronic medical needs by making home visits and directing them to an appropriate primary care physician instead of the ER.  The team also goes along on doctor’s appointments, helping ensure patients’ needs are acknowledged and addressed. 

PCIC’s program is already working. Among participants in the PCIC program, there’s been a 56% reduction in 911 calls, 67% reduction in ambulance trips to the ER and a costs savings of $114,640. In addition, the PCIC team has collected extensive data and records from 13 community partners to help identify more super-utilizers.

Mr. B was one of the first patients in Houston to sign up for PCIC’s program. Although his condition is rare, PCIC’s team helped identify that his mother’s use of beans was a key factor in driving his health crises.  Following an appropriate nutritional diet and with a few changes in medications, his health dramatically improved.  Now, he can walk without assistance, he’s happier, and no longer relies on ambulances or hospitals.

“He has much better health at a much lower cost,” Buck said. “Coordinating his care and addressing the root cause of his ER visits is an example of how an effective safety net can work.”

“The improvements to the well-being of these vulnerable patients are life changing,” said Elena Marks, EHF’s president and CEO. “By working at a systems level, the cost savings are passed on, resources are now used more efficiently, and the capacity of the entire healthcare system expands.”

EHF’s $150,000 grant will help PCIC develop a county-wide care coordination program for similar “super-utilizers”. The program’s goal is to coordinate care for around 150 patients by December of 2016, reduce ER visits by at least 30%, and add more hospitals and partners to the project.

Right now, participants in PCIC’s coordinated care system include the Houston Fire Department, Harris Health System, Houston Police Department, Memorial Hermann Hospital System, Healthcare for the Homeless-Houston and more.

Learn more about PCIC