Indiana Regional Medical Center is one of six community hospitals selected by the Pittsburgh Regional Health Initiative (PRHI) to participate in their three-year innovation grant from the Center for Medicare and Medicaid Innovation (CMMI) to implement a Primary Care Resource Center (PCRC) model of care in a network of independent community hospitals and their aligned physician practices.
That’s a lot of acronyms and initials. What does it mean to IRMC and more importantly, to you?
The principle goal of this initiative is to reduce the number of 30-day readmissions.
That means we want to get you healthy and keep you healthy — the first time.
It’s important for you because no one wants to go back to the hospital once they’ve been discharged for any reason other than a follow-up visit.
It’s important for IRMC because we will be reimbursed based on our ability to provide exceptional patient care.
The PCRC will serve as an extension of primary care practices, improving the transitions of care from the hospital to outpatient care for target patient populations at risk for high readmissions (patients with chronic obstructive pulmonary disease, heart failure, and acute myocardial infarctions), ensuring they continue to get the medical and other services they need in order to keep them from returning to the hospital.
How does IRMC plan to do this?
By employing nurse care coordinators and a pharmacist, we will take a proactive approach to your discharge and your home care.
The PCRC will serve as the “home base” for the management of patients with the target diseases.
The PCRC team will meet with the patient upon admission, follow their progress and then work to ensure a smooth discharge.
Each patient will be educated by PCRC staff on the management of their disease, receive medication reconciliation by the PCRC pharmacist, have follow-up appointments made, and a home visit or PCRC appointment scheduled — all before the patient leaves the hospital.
Communication with the patients’ primary care physician office helps to keep patients on track with treatment plan.
The PCRC also offers services that primary care providers may not have the resources to provide, such as smoking cessation, nutrition counseling, anticoagulant management, inhaler training and more.
We all need help sometimes.
You are worth it.