PHCS Part of Historic Effort to Improve Care, Reduce Costs

Jun 5, 2013

Princeton HealthCare System (PHCS) 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.

Princeton Medicine, PHCS' primary and specialty medical care practice, is one of 72 practices in New Jersey and only 500 across the United States chosen by the federal Centers for Medicare and Medicaid Services (CMS) to participate in the project, known as the Comprehensive Primary Care Initiative. Managed by the Innovation Center within CMS, the initiative was made possible by the Affordable Care Act.

"The goal is to keep our patients healthier by ensuring that they receive proactive, coordinated care," said David Lazarus, MD, 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."

Dr. Lazarus said 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, said Dr. Lazarus.

When the initiative began, physicians at Princeton Medicine used the practice's electronic health record (EHR) 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 EHR 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 EHR and access the patients' records remotely at night and on weekends.

Princeton Medicine's EHR 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 physicians.

"Our EHR is critical in allowing us to better coordinate the care of our higher risk patients," said Tobe Fisch, MD, one of the primary care physicians involved in organizing the initiative at Princeton Medicine. "In fact, one of the criteria used by CMS in selecting us for this program is that we have already met federal standards for meaningful use of electronic records."

"This is a time of great change," Dr. Lazarus said. "This program gives us an opportunity to be part of the solution in making healthcare more affordable and efficient while at the same time providing high-quality care to each patient."

To find a Princeton Medicine physician, call (800) FIND A DR (346-3237).

About Princeton HealthCare System
Princeton HealthCare System is a comprehensive, integrated healthcare system that strives to anticipate and serve the lifelong needs of central New Jersey residents, including acute care hospital services through University Medical Center of Princeton at Plainsboro, behavioral healthcare through Princeton House Behavioral Health, rehabilitation, home care, hospice care, ambulatory surgery, a primary and specialty medical practice, and fitness and wellness services. For more information, visit

Andy Williams
(609) 252-8785