From Calcutta to Houston: Technology-driven care coordination for social determinants of health

September 19th, 2018 / By L. Gordon Moore, MD

That’s the tagline for the Patient Care Intervention Center (PCIC), a nonprofit working with people living on the streets in and around Houston, Texas. It started with family medicine physician David Buck, MD, learning about street medicine in India with Mother Teresa and evolved into street medicine in Houston.

Dr. Buck found that he needed a better way to track important medical and medically related information than what was available. Over time and with colleagues he developed tools to integrate information across medical and social service agencies to better support care delivery. He and Kallol Mahata, COO developed the PCIC as a vehicle to develop and deliver information technology across the multiple agencies and entities that intersect with very vulnerable people.

I had the pleasure of recording a podcast with Mr. Mahata & Dr. Buck as they described their evolution and the impressive results of their work: millions of dollars in avoided costs, a 52 percnt reduction in emergency department visits, improved quality of life measures and more.

The PCIC is an example of how we can use technology to leverage partnerships across multiple entities serving the same people and achieve improved care coordination and outcomes. I’m impressed by how many partnerships and agreements PCIC has put in place. This is possible because of PCIC’s understanding of the broad impact of their work. If—for instance—they can more effectively meet the needs of a person with severe and persistent mental illness, they might not only reduce unnecessary emergency room visits, but they might also reduce unnecessary arrests, jail and court time—outcomes of broad benefit to society.

This example working with an extremely vulnerable population can be replicated in other settings and translated to improve care coordination for groups with significant yet not as extreme needs.

L. Gordon Moore, MD, is Senior Medical Director, Clinical Strategy and Value-based Care for 3M Health Information Systems.