Program officials, medical staff and dignitaries toured the new onsite Primary Care Resource Center (PCRC) at Monongahela Valley Hospital last week. The PCRC is the non-profit hospital’s latest effort to better serve patients by reducing readmissions. The center also helps physicians who manage the care of patients with chronic diseases.
MVH nurse care managers and a pharmacist will interact with and counsel patients with conditions such as chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and coronary artery disease (CAD), beginning at the time of the patients’ admission to the hospital.
The new center was created in conjunction with the Pittsburgh Regional Health Initiative (PRHI)’s Pittsburgh Accountable Care Network (PACN) project and is a pilot program that will grow to include other western Pennsylvania hospitals, which will be named at a later date.
The goal is to reduce 30-day readmissions for those with chronic conditions such as COPD, CHF and CAD, and to serve as an extension of primary care physicians’ practices.
Under the direction of PRHI’s Chief Medical Officer Keith T. Kanel, M.D., this readmission-reduction project at MVH builds on a PRHI-led hospital-physician project that achieved a 44 percent reduction in readmissions for COPD patients. Medicare will soon begin to impose penalties on hospitals with high readmission rates for selected chronic diseases.
Dr. Kanel said the PCRC engages patients as soon as they come to the hospital, providing additional counseling on all aspects of their plan of care, including medications, diet and nutrition, diabetes education and even smoking cessation. Normally, instructions are given only at the time of discharge.
“The PCRC will be a valuable resource for primary care physicians whose patients struggle with chronic illnesses,” said Donna Ramusivich, senior vice president at Monongahela Valley Hospital who oversees the initiative. “This hands-on, personal and proactive approach will benefit our patients and their doctors.”
In mid-June, the staff at the new center began seeing patients. The staff are Cara Anderson, PharmD; Nurse Care Managers Deborah Holman, RN; Sharon Nash, BSN, and Lead Care Manager Susan Campus, BSN, MS.
They work with primary care physicians to ensure that COPD, CHF and/or CAD patients are knowledgeable about their disease and understand their treatment plans. They send progress reports to patients’ primary care physicians after every PCRC visit and will conduct a post-discharge home visit with patients to follow-up on a patient’s and caregivers’s understanding of their plan of care. If additional visits are needed, appointments will be made for further follow-up with patients and their caregivers visiting the PCRC offices. MVH’s Primary Care Physicians may also refer patients to the PCRC from their offices if they see a learning need that may require increased counseling or additional care coordination.
Dr. Kanel and Ms. Ramusivich both said they would like to see the program become “part of the fabric of the health care community.”
In addition to Dr. Kanel, Karen Wolk Feinstein, Ph.D., president and CEO of the Pittsburgh Regional Health Initiative, and Louis J. Panza Jr., president of CEO of MVH, addressed guests at the open house event.
The Pittsburgh Regional Health Initiative develops and manages programs, research, training and grantmaking to perfect patient care, focusing on new models of care, such as the Primary Care Resource Center program at MVH. PRHI received a Highmark Blue Cross/Blue Shield grant that will fund the Primary Care Resource Center project for three years.
Read more about their organization at www.prhi.org.