The Primary Care Resource Center: A New Model for Complex Patients

Through the Primary Care Resource Center (PCRC) Project, the Pittsburgh Regional Health Initiative (PRHI) equipped six local community hospitals with the quality improvement, advanced disease management, and motivational interviewing skills to provide patients with chronic health conditions with one-stop, coordinated outpatient care — while achieving both readmissions reductions and cost savings.

The PCRC project, funded by a $10.4 million Center for Medicare and Medicaid Innovation (CMMI) grant, focused on patients with chronic obstructive pulmonary disease, acute myocardial infarctions, and/or heart failure. During the CMS grant phase of the project (Fall of 2013 to Fall of 2015), the six PCRC sites collectively achieved a 25% reduction in all-cause 30-day hospital readmissions for enrolled patients. The PCRCs also generated more than $1,000 in post-acute care savings per patient during the first 90 days following discharge, compared to a control cohort.