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Admin & Clinical Operations Mobile Integrated Health: Can We Decrease Patient Returns to the ED?
Mobile Integrated Health: Can We Decrease Patient Returns to the ED?
By Rida Farook; Thomas Hagerman, MD; Michael B. Holbrook, MD, MBA; Thomas Derkowski, MHA, CCEMT-P; Sean Drake, MD; Matthew Ball, MD; and Joseph Miller, MD, MS on behalf of the SAEM ED Administration & Clinical Operations Interest Group
The transition from the emergency department (ED) to home carries risks for a substantial proportion of ED patients. These risks are particularly present among vulnerable patients who have barriers to timely outpatient follow-up. One potential solution to mitigate risk and improve overall patient care is the introduction of Mobile Integrated Health (MIH) and Community Paramedicine programs (MIH-CP). These programs were first introduced in 1992 to address health care disparities experienced by patients in rural communities. Eventually, MIH-CP programs expanded beyond rural areas into suburban and urban communities to meet patients at their homes to address wellness, disease prevention, post discharge care, and medical compliance. In the past ten years, there has been a substantial increase in the number of these programs and the breadth of care provided. Existing small studies suggest that MIH-CP programs may reduce ED re-visits, improve the efficiency of patient care, and are associated with overall cost reduction. For example, when MIH-CP programs were implemented in Nova Scotia, ED readmissions were reduced by 23% in 2002 and 2003. The MedStart Mobile Health Program in Dallas-Fort Worth, Texas avoided 1,893 transports to the ED between January 2010 and February 2015, with an average patient satisfaction score of 4.9 out of 5. It also saved an average of $7,620 on payment charges per patient impacted by the program. Additionally, in the program in Dallas-Fort Worth, the readmission rate
“Existing small studies suggest that MIH-CP programs may reduce ED re-visits, improve the efficiency of patient care, and are associated with overall cost reduction.” for enrolled patients with congestive heart failure was found to be only 16.3% compared to the national readmission rate of 23%. In terms of patient costs, the MIH run by Niagara EMS in Ontario, Canada saved $171,573 per onethousand calls compared to regular ambulance responses in 2018. In Los Angeles, MIH and CP programs particularly assisted people experiencing homelessness in managing their health as they were found to have a 19 times higher rate for ambulance transport prior to implementation of these programs. Additionally, in terms of increasing care
efficiency, patients directed to a mental health agency via an MIH spent an average of 26 minutes waiting for care compared to hours or even days when sent to the local ED.
Henry Ford Health, an integrated health system in southeast Michigan, implemented an MIH program in 2020 with the intention of providing postdischarge assistance with patient health literacy, prescription support, home safety, and virtual physician visits. Patients are referred to the MIH program through not only the ED, but also general post-discharge and outpatient clinics. Paramedics that provide home visits have on-call physician support to guide management decisions and provide virtual visits using video and TytoCare technology. The MIH team provides all services at no cost to patients.
Since April of 2020, the MIH team at Henry Ford Health (HFH) has had over 7,990 home encounters. Around half of all referrals come from the ED with remaining coming from inpatient units, outpatient primary care physicians, and specialists. Among patients seen by MIH, 42% had Medicare or Medicaid insurance and 53.2% had an annual income less than $41,000. Around 49% of patients were non-Hispanic black. About 67% of the patients enrolled in the program had one or more chronic disease,s including but not limited to hypertension, diabetes mellitus, chronic kidney disease, and congestive heart failure. Interventions have included patient education (47.4% of encounters), medication reconciliation (33.3%), medication administration (10.3%), and emergency food box provision (2.5%). During the pandemic, the program provided home infusions of monoclonal antibody treatment to more than 400 high-risk patients with COVID-19.
Encounters in the ED are costly and time-consuming, and discharged patients face a wide array of barriers to adequate follow-up and continued care after their encounter. While requiring substantial up-front investment, MIH-CP programs can be powerful for bridging the gap between the ED and recovery at home. Further research into the effectiveness of MIH-CP interventions on patient outcomes is currently being conducted. The HFH MIH team is participating in a PCORI funded implementation project to improve education and self-care in patients with acute heart failure after their ED encounter. This implementation project will track whether improving patient self-care reduces ED and hospital re-admissions. Further work to improve reimbursement strategies through Medicaid and commercial plans is also underway as systems such as HFH aim to close care gaps and provide high-value care to their most vulnerable patients. Rida Farook is a second-year medical student at Wayne State University School of Medicine.
Dr. Hagerman is a third-year resident in the combined emergency medicine and internal medicine residency at Henry Ford Hospital.
Dr. Holbrook is an operations and administration fellow at the University of Cincinnati and previously served as chief resident at Henry Ford Hospital. holbromb@ucmail.uc.edu
Thomas Derkowski is the director of Henry Ford Health Mobile Integrated Health and has more than 30 years of EMS experience. He is a member of the board of directors for the National Association of Mobile Integrated Health Providers and the committee chair for Training & Education. tderkow2@hfhs.org
Dr. Drake is the medical director for Complex Primary Care for Henry Ford Health. He is boardcertified in internal medicine and has worked in a variety of roles including inpatient rounding, outpatient clinic, and teaching. He oversees the Comprehensive Care Centers and the Virtualist Physicians for the Mobile Integrated Health Program. sdrake1@hfhs.org
Dr. Ball is the lead ED physician consultant for Mobile Integrated Health and completed an emergency medical services fellowship at The Ohio State University School of Medicine. mball1@hfhs.org
Dr. Miller is a clinical associate professor of emergency medicine and internal medicine at Henry Ford Hospital. jmiller6@hfhs.org
