Primary Care Resource Center (PCRC)

Initiatives

Care Coordination
RN Case Managers provide outreach to complex, high-risk patients with specific diagnoses, with a primary goal of educating the patient on their disease state and treatment plan, as well as offer solutions to prevent readmission. These solutions range rom transportation assistance, facilitating appointments with their primary care provider or specialist, assist in placing patients in a higher level of care from home or the emergency department, and providing self-management equipment (e.g. scales, pill boxes, blood pressure cuffs) to patients in need.

Chronic Disease State Management
RN Case Managers and Pharmacist staff provide outreach to patients to provide education on their disease state and treatment plan, as well as lifestyle counseling, medication education, and medication adherence. Pharmacists will collaborate with primary care providers to offer patient specific support and medication review.

Post-Acute Provider Collaboration
Our staff works closely with post-acute facilities to ensure smooth transitions of care from hospital to post-acute care to home. Frequent touch points with post-acute providers aids in the effort to prevent readmissions and provide quality care to patients. Our department facilitates InterACT training with post-acute providers, which is a quality improvement program that focuses on reducing unnecessary admissions to the hospital.

Clinically Intergrated Network (CIN)
Our team works directly with the CIN by contributing to care coordination, chronic illness management, and preventative care. We work with primary care providers in the CIN to achieve the best quality for patients by addressing gaps in care, medication adjustments, patient advocacy, and health and wellness promotion. Additionally, we collaborate with insurance providers in order to achieve success in the CIN's various value based on reimbursement programs.

To learn more about Advantage Point Health Alliance - Laurel Highlands, visit here.