Princeton HealthCare System is participating in a federal pilot project to provide coordinated, preventive medical care, particularly for patients with chronic conditions, in an effort to reduce hospitalizations and emergency room visits. The initiative is part of the Affordable Care Act of 2010.

Princeton Medicine, PHCS’ primary and specialty medical care practice, is one of 72 practices in New Jersey and 500 across the United States chosen by the federal Centers for Medicare and Medicaid Services to participate in the project, known as the Comprehensive Primary Care Initiative.

“The goal is to keep our patients healthier by ensuring that they receive proactive, coordinated care,” says Dr. David Lazarus, chairman of the Department of Medicine at PHCS and president of Princeton Medicine. “This is better for the patient, of course, and also saves money in the long term by reducing hospital admissions or readmissions and unnecessary trips to the emergency department.”

Lazarus says the effort uses a team approach, with a physician, advance practice nurse, and an outreach nurse collaborating on each patient’s care. Patients also have access to a social worker and assistance with managing prescriptions.

There is no additional cost to the patient, Lazarus says.

When the initiative began, physicians at Princeton Medicine used the practice’s electronic health record system to identify some 600 patients who might benefit from the more intensive, team-oriented approach to care. The list included patients with combinations of chronic health conditions that put them at higher risk for complications or hospitalization; patients who had been admitted to the hospital within the previous year; and patients who take multiple medications for different conditions. The patients are primarily covered by Medicare and two private plans — Horizon Blue Cross Blue Shield of New Jersey and United Healthcare — that are participating in the initiative.

The electronic health record system allows Princeton Medicine to personalize and coordinate the patients’ care. The system is used to track hospitalizations and ER visits; monitor whether patients make appropriate follow-up visits to their primary care physicians and specialists; order all medications; and help ensure that best practices guidelines for patient care are being met.

Customized tools for geriatric assessment and for generating individualized care plans are also available. Physicians and nurses within the group can communicate through the health records system and access the patients’ records remotely at night and on weekends.

Princeton Medicine’s system is fully integrated with Princeton HealthConnect, the Health Information Exchange of PHCS’ acute-care hospital, University Medical Center of Princeton at Plainsboro. Through this integration, reports transcribed at the hospital and the results of any tests or procedures performed there are incorporated into patients’ electronic records and become immediately accessible to their primary care doctors.

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