Patient Care Intervention Center

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Patient Stories

Ms. Loretha

Dreams have become reality

An extreme utilizer of Emergency Medical Services (EMS) calls and transports, Ms. Loretha felt powerless managing her health. Struggling to manage COPD, anxiety, depression, and chronic headaches, she felt trapped - afraid to go outside for fear of exacerbating her COPD.

Fortunately, we identified her through fire department data as a High-Need, High-Cost patient, and intervened coordinating health and social care, providing advocacy, building trust, and linking her to a provider.

When our team first started working with her, she could not walk the length of her driveway without becoming short of breath, but she successfully graduated accomplishing six months of our Intensive Care Management program, and is proud to say she can now coordinate her own care.

Dreams becoming reality, Ms. Loretha can run around outside with her grandchildren without becoming short of breath.



Ms. Cynthia

Successfully completed our program for a better tomorrow

Hungry. Homeless. Ms. Cynthia, a diabetic and former drug addict, struggled with high blood pressure and lupus. She frequently called 911 when she didn't feel well. Missed doctor appointments were the norm due to her transportation challenges. Then a disengaged partner became detrimental. Realizing she'd hit rock bottom, she was open to help. PCIC reached out by setting up dependable transportation to help her keep appointments. Services were set up for a glucometer and lancets. Training to log blood glucose levels was provided. A PCP and other specialists were also arranged. She has continued to lean on us for support when she reverts to unhealthy patterns.



Ms. Cecelia

PCIC didn't give up, so why should she

After the death of her mother, Ms. Cecilia lost her life-long companion and primary care-taker. Unable to live independently, her living conditions and medical care took a sharp decline. Constant falls and HFD transports related to unmanaged diabetes and congestive heart failure made it difficult for Ms. Cecilia and her family to cope.

After PCIC's intervention, Ms. Cecilia transitioned to a supportive nursing facility and got connected with specialty physicians focused on stabilizing her conditions. She has had a 81% reduction in ER visits and hospital admissions.



Mr. Lee

Saving lives

Until early 2000, Lee worked as a surveyor in Texas and enjoyed the outdoors. However, he caught our attention as a likely High-Need, High-Cost candidate in early 2015 because of his repeated 911 calls. When we reached out to him, we found him wheelchair-bound, enslaved to alcohol, severely undernourished and alone. He had become a High-Need, High-Cost patient mainly because of his chronic pain. Despite his enrollment he remained reclusive and uncooperative until one fateful day in April, when we found him at the end of one of his severe drinking binges.

He was lying in bed, soiled and hungry from going days without eating. He said he wanted to end his life. His blood alcohol level was five times the legal limit. Lee was admitted for medical detox on the same day, followed by psychiatric care one week later. With the assistance of the Mobile Crisis Outreach Team and "A Place for Mom" we were able to coordinate with both Lee and his brother in finding an assisted living facility. Lee now benefits from regular meals, appropriately dispensed medications as well as a Primary Care Physician who oversees his chronic medical problems. Until PCIC came into Lee's life, his family had thought he was a 'lost cause' since he had given up on himself. With the help of our team, his health continues to improve and he's able to manage his pain and alcohol dependency. His family once again is taking an active part in his life and he no longer needs to call 911 for medical care.



Mr. Jesse

Thank you for always showing up

Sleeping on a bench outside his family home, Mr. Jesse constantly cycled in and out of the ER as his blood sugars alternatively spiked and plummeted. Without consistent access to food or insulin, he struggled to manage a particularly treatment-resistant case of type 2 diabetes. Years of struggling with unmanaged diabetes and homelessness had left him in chronic pain and without hope.

PCIC and Mr. Jesse worked together to find a new home and connect him with the medical and social services he needed. Since PCIC's intervention, Mr. Jesse is stably housed and well-supported with a 50% reduction in ER visits and hospital admissions.



Mr. Randy

PCIC intervention helping improve quality of life

Randy worked on an oil rig, and after enduring a traumatic injury on the job, his life became challenging as he lost his job, his family, and his home. Feeling discouraged, he became an alcoholic and enrolled in rehabilitation programs; but that did not help him address the unknown causes for his seizures. Because he was homeless, 911 was usually called by a bystander who witnessed the seizures.

Having attended several programs that failed him, he was surprised and pleased to see that PCIC was consistent and passionate about helping him. Through care coordination we connected him with a primary care physician, decreased his ER visits, and he hasn’t had a seizure since enrolling.

During this time he’s also managed to develop a healthier relationship with his son, who is his motivation to get his health and addictions under control. He has been very compliant and cooperative throughout the entire process, and has maintained a very positive attitude towards improving his health.



Mr. Travis

It may be stormy now, but it never rains forever

Suffering from priapism and high blood pressure, Mr. Boone, a timid and shy man felt hopeless and depressed. This childhood disease revealed in adulthood made him fear for his life. A needed change in diet spurred his well-intending mother to cook foods that exacerbated his condition.

When asked what he should do when he had flare ups, a health professional directed him to "just call 911", and prescribed him counter-productive medications. PCIC intervened to coordinate his care. We found him a new doctor, helped guide dietary and lifestyle changes, and nourished his will to live. A new confidence and motivation enabled him to self-advocate resulting in a 75% reduction of ER calls, and most importantly, he was now in control of his life.



PCIC intervention helping improve quality of life


Mr. Arthur

Mr. Arthur now has positive attitude towards improving his health.

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Our Vision

At PCIC we envision a coordinated health safety-net where all stakeholders share data to make better decisions.

Our Mission

To improve healthcare quality and costs for the vulnerable in our community through data integration and care coordination.

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