The Tribune Democrat, Johnstown, PA

Local News

October 14, 2013

Memorial launches transition center

Unit will aid patients after hospital stay

JOHNSTOWN — At the grand opening of Conemaugh Memorial Medical Center’s Primary Care Resource Center in the hospital’s Crossroads Cafe on Monday, some startling figures related to patient transition were presented:

One in five elderly patients will be readmitted to the hospital within 30 days of discharge, one out of three patients can’t explain their prescribed medications and half can’t even state their diagnosis.

Also, three out of four patients wouldn’t need a return trip if there were a plan for follow-up care in place. According to administrative officials and physicians from the region and Pittsburgh, who collaborated on Conemaugh’s new transition program, the PCRC aims to see that happen.

The PCRC will help physicians and patients coordinate ongoing care of chronic diseases, specifically chronic obstructive pul­monary disorder, congestive heart failure and myocardial infarction, or heart attack.

Discharged patients transitioning to home or other outpatient care will make scheduled PCRC visits. They’ll learn about their diagnoses, “red flags” for necessary readmission and proper home or outpatient care methods. Some of the other educational courses offered cover inhalers, smoking cessation, nutrition and diabetes.

“The PCRC is to fill gaps that we know are already existing in health care. Patients leave without enough information, without enough training, without the confidence,” said Dr. Keith Kanel, chief medical officer of Pittsburgh Regional Health Initiative and the project’s director.

According to Dana Begley, Conemaugh’s vice president of medical management and administrative go-to for the PCRC project, the center will have five full-time staff members: three registered nurse case managers, a pharmacist and an administrative assistant.

“I believe that it is our obligation to hand the baton to the next care provider, whether it be a skilled nursing facility, an outpatient center or at home to another family caregiver,” Begley said.

Memorial Medical Center is one of seven hospitals participating in the program. The others are Butler Memorial Hospital, Indiana Regional Medical Center, Monongahela Valley Hospital, Sharon Regional Medical Center, Uniontown Hospital and Wheeling Hospital.

Kanel said that since Monogahela Valley Hospital began its program a year ago, 30-day readmission rates were nearly halved.

“The biggest barrier is that nobody pays for this service,” Kanel said. “Medicare

doesn’t pay for it, the big health insurers do not pay for it. And if it doesn’t get paid for in health care, it doesn’t get done.”

But the service will be free to all patients, regardless of insurance, for the next two years through a $10.4 million Health Care Innovations Award grant.

In January 2012, Medicare began receiving grant proposals for patient transition programs. In a race among more than 3,000 applicants, only 107 grants were awarded, including Pittsburgh Regional Health Initiative, which was the only awardee in the western Pennsylvania region.

“(Now) we have two years to make the case to Medicare and to the insurers that this delivers value – you save money if you provide this care. We want to build the business case for doing this,” Kanel said.

Justin Dennis is a multimedia reporter for The Tribune-Democrat. Follow him on Twitter at

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