Eligibility & IdentificationEligible super-users identified for PCIC's program have 4+ hospital admissions per yr., or 10+ ER visits per yr., and 2+ chronic conditions. The identification is performed by analyzing large datasets, looking at the previous 12 months of utilization at a specific hospital system. Once identified, the client's medical history is reviewed, their case is opened and the client is ready for enrollment. PCIC manages 15 clients per 4-month cycle.
EnrollmentThe client is engaged and enrolled as a client at the hospital or their home, and initial team visits focus on building mutual trust, identifying root causes of utilization and defining trigger events. Care plans are developed by mutually identifying goals with the client. Pre-intervention utilization, costs, quality of life measures (through DLA-20), and the ACE (Adverse Childhood Experiences) score are conducted and evaluated.
Care Management InterventionOur intervention team (Social Workers, Community Health Workers, Medical Assistants & RN's/MDs) coordinate the client's PCP and specialist appointments, pharmacy (medication reconciliation), as well as coordination of transportation, social security benefits, insurance, housing, food insecurities, employment & other social resources needed to stabilize the client. The team educates clients toward improved decision-making and self-advocacy. Care management and follow ups are performed with each client on a weekly basis.
Assessment & EvaluationThe client's performance in the intervention program, their quality of life and their utilization of services (cost & visits) are monitored and evaluated throughout the intervention period. Dashboards are developed at the client, provider and system level to measure progress, and are reported to the client PCP's, Specialists and referral organization.