A patient is discharged from a hospital, returns home, encounters complications, calls 9-1-1 and ends up right back in the hospital. This unfortunate scenario plays out nationwide every day, but there are alternative models being developed in communities across the United States.
These patient-centric delivery models are generally referred to as examples of “mobile integrated healthcare” (MIH), a term used to emphasize the importance of making care available in many different sites of service. Many of these programs incorporate expertise from EMS experiences, with care provided by MIH paramedics, or sometimes called “community paramedics.”
As is realized firsthand from traditional EMS experience, a large proportion of patients call 9-1-1 not because they’re having an emergency but because they’re seeking entry into the healthcare system. Studies have suggested that these acute care patients account for up to one third of all EMS patient encounters and that approximately 8% of the U.S. population accesses healthcare via EMS each year.2,3
These novel care delivery models ensure the right care is delivered to a patient at the right time, in the most appropriate setting and in the most cost-effective manner. The notion is that if patients are offered meaningful alternatives to inappropriate ED utilization they’ll make a wise decision.
It’s important to note that MIH programs aren’t intended to create gate-keeping systems that force patients to choose particular sites for care. Rather, the goal is to create value by providing clinically appropriate care with an interprofessional team.
An interprofessional team, including an MIH paramedic and an advanced
practice provider, coordinate patient care through every stage of the patient’s healthcare.
Although they differ from one another in many ways, one thing MIH programs have in common is that they’re designed to meet the goals of the Institute for Health Improvement’s (IHI) Triple Aim: 1) improve the health of the population; 2) enhance patient experience and outcomes; and 3) reduce the cost of care.1
Using a broad range of resources including community health workers, paramedics, EMTs, nurses, social workers, pharmacists, physician assistants, nurse practitioners and physicians, MIH programs provide services accessible 24/7 across all phases in the continuum of care, including acute and chronic care as well as preventive services.
Ideally, each program begins with a needs assessment, the results of which identify gaps in care and inform decisions regarding how to fill those gaps. In our experience, commonly identified gaps include decreased availability of care on nights and weekends, medication therapy management and methods to address psychosocial determinants of health. Whatever the identified gaps, successful MIH programs will purposefully create an interprofessional team whose members have the skill and expertise to close the gaps in a meaningful way.
Although the concept of MIH is only a few years old, a number of studies have demonstrated the positive impact of such programs. One study reported that approximately $600 million in annual savings could safely be achieved if low-acuity Medicare patients were transported by EMS to settings other than an ED.4
In Reno, Nev., a program that includes a nurse advice line, alternative destinations for EMS transportation and use of community paramedics in helping with transitions of care has produced positive results regarding patient experience, health of the population, and cost effectiveness.5
MedStar Mobile Healthcare in Fort Worth, Texas, has a robust program with telephonic and in-person interventions that have yielded promising results.6
The Wake County EMS System has demonstrated positive results as well, particularly as it relates to alternative destinations for patients with mental health and substance abuse and for patients who experience simple falls in assisted living facilities.7,8
Finally, the International Roundtable for Community Paramedicine maintains a set of resources and information.9
Many of these MIH programs focus on patients who were already known to the EMS system, either after a 9-1-1 call or some other referral for a specified request.
To our knowledge, no report regarding a statewide MIH model is in the literature, and we’re pleased to share our experiences with a statewide MIH program as was recently published in the Journal of Health Economics and Outcomes Research. This study specifically examines the results of an MIH program built to provide and coordinate both planned and unplanned patient care for a defined Medicare population.10
Field providers rely on the expertise of a clinical pharmacist to
educate patients and give them the appropriate level of intervention.
Statewide MIH Model
The Evolution Health model is a physician-
led, interprofessional care model that set out to reduce preventable readmissions and enhance the patient and caregiver experience while reducing the overall cost of managing patients.
It was designed to provide comprehensive services with a focus on:
- Providing 24/7/365 clinical care;
- Providing in-home clinical assessments;
- Supporting transitions between levels of care;
- Managing long-term needs for high-risk individuals;
- Supporting goals of care for advanced illness management; and
- Creating alternatives for unplanned care needs.
The results published by Evolution Health specifically focused on the program’s efforts of coordinating care for high-risk members, including those with advanced illness and chronic disease, as well as those transitioning from one care setting to another (e.g., from the hospital or a skilled nursing facility to the patient’s home.)
The population included in the study consisted of 60,000 Medicare Advantage members. Depending upon disease severity and risk, these members were offered telephonic health coaching, in-person assessments, social work, pharmacy assistance, and other care management services appropriate for them.
All members had access to the medical command center on a 24/7 basis in order to provide unplanned care needs. Our program is specifically designed to maximize patient choice, giving patients a broad menu of meaningful alternatives on both a scheduled and an unscheduled basis.
The Evolution Health MIH program relies heavily on the expertise of EMS personnel and took on an EMS-like system design to manage, prioritize, schedule and respond to clinical requests, as well as to track community health resources. EMS systems and providers proved to be a natural fit and made an ideal partner for pioneering this new approach to providing patient-centered care for the acute and chronically ill while also tending to urgent and non-urgent events.
Patients in the Evolution Health MIH program are cared for by a team of clinicians who operate within their scope of practice. The program’s design encourages interprofessional teamwork and top-of-licensure care.
For example, patients transitioning from the hospital to their home may have an MIH paramedic perform the initial transitional care visit in consultation with a pharmacist located in the program’s Medical Command Center (MCC), who assists with medication reconciliation. Subsequent visits to this patient may include a social worker, physician assistant, nurse practitioner or physician depending upon the patient’s need. As needs or goals of care plans change, patients may be referred to a home health provider or visited by a palliative care specialist.
Selecting the primary site where scheduled care is provided is driven by patient choice and usually occurs in the patient’s home. Scheduled, planned maintenance is typically the primary goal of MIH programs, but they also must be able to manage unplanned changes in patient condition or rapid illness exacerbation.
Available to all Evolution Health program participants, 24/7/365 Unplanned Care events are triaged based on a five-point system, ensuring patients receive time- and needs-appropriate resources, which range from immediate dispatch of 9-1-1 EMS resources to scheduling a follow-up appointment with a primary care physician. These unscheduled interventions may be treated in the home, primary care office, urgent care or, rarely, in an ED.
The Evolution Health MIH team is coordinated via the MCC, which functions similar to an EMS communications center with layers of additional clinical resources and access to detailed patient data.
Evolution Health uses two MCC facilities supported by virtual providers across the United States to bolster the infrastructure and allow for redundancy. MCCs are available 24/7 and provide callers with triage for unplanned care, coordinate team member response to scheduled and unplanned care, monitor patients remotely and facilitate telemedicine consults between on-call physicians and field providers. The MCC staff has real-time access to patient medical records to help identify critical needs, aid in triage decision-making and inform clinicians during telemedicine consults.
The results published by Evolution Health’s multidisciplinary MIH program measured the care delivered by an interprofessional team for one year in a population of approximately 60,000. Fifty-five percent of participants were female and with a mean age of 71.2 years. During this time, there were 89,788 outreach and care calls, 11,849 in-person wellness and prevention visits, and 686 responses to calls for unplanned care.
This study measured the financial, clinical, and patient experience components of our interventions. The financial and clinical impacts were measured in two ways. First, comparison was made against contemporaneous, risk-matched nonparticipants. Second, comparison was made between the actual experience vs. actuarially expected cost and utilization based on historical claim experience. The overall goal is to determine the true value being created for all stakeholders rather than evaluating discrete savings for one stakeholder that may or may not reduce the overall costs of care. The patient experience component was measured by a third party survey.
The study showed that using this multidisciplinary approach not only improves patient care but reduces overall cost. Eligible members participating in the program realized a 21% reduction in ED utilization along with a 40% decrease in inpatient medical utilization. This was associated with reduction in per member per month costs of 19% for ED services and a 37% for inpatient medical services. This combination of reduction in utilization and costs clearly demonstrates the MIH program created value. (See Figure 1.)
Whatever value is created for payors or health plans will have limited impact if the patients do not embrace the MIH program. Indeed, reduction in costs or utilization must be balanced by patient safety and satisfaction. The safety of the Evolution Health triage algorithm will be reported at the annual meeting of the National Association of EMS Physicians in January 2017.
The satisfaction of patients is demonstrated by the fact that 97% of patients felt that the provider of healthcare was knowledgeable, and that 96% would recommend this MIH experience to friends and family. While our satisfaction survey isn’t identical to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), they do have a similar question regarding “definitely recommending a hospital” with a national average of 72% patients making such a recommendation.11
The authors of the study believe it’s the first peer-reviewed study demonstrating the effectiveness of MIH on a large population, meeting the three-pronged goals of the IHI Triple Aim by improving the quality of care, reducing costs and enhancing patient experience.
Further studies from Evolution Health’s MIH program as well as others that are underway may show similar findings, where innovation, collaboration and excellence result in positive patient experiences, improved outcomes and decreased costs. This could eventually lead to improvement in healthcare value for all stakeholders across the care continuum. jems
1. Berwick DM, Nolan TW, Whittington J. The triple aim: Care, health, and cost. Health Aff (Millwood). 2008;27(3):759–769.
2. Robert Wood Johnson Foundation. (Feb. 11, 2013.) The revolving door: A report on U.S. hospital readmissions. Retrieved Oct. 28, 2016 from www.dartmouthatlas.org/pages/readmissions2013.
3. McCallion T. And the survey says: NASEMSO analysis provides snapshot of EMS industry. JEMS. 2012;37(1):34–35.
4. Alpert A, Morganti KG, Margolis GS, et al. Giving EMS the flexibility in transporting low-acuity patients could generate substantial Medicare savings. Health Aff (Milwood). 2013;32(12):2142–2148.
5. Gerber M. Guardian angels: How an EMS system in Reno, Nev., watches over post-discharge patients to avoid costly readmissions. JEMS. 2015;40(3):54–57.
6. Mobile healthcare programs—Overview. (2016.) Medstar Mobile Healthcare. Retrieved Oct. 30, 2016 from www.medstar911.org/mobile-healthcare-programs.
7. Glickman S, Bachman MW, Williams JG, et al. An advanced practice paramedic program can safely and effectively divert acute mental health patients from an ED to a community mental health center. Acad Emerg Med. 2014;22(5):S25–S26.
8. Bachman M, Myers J, Williams J, et al. Emergency medical services evaluation of falls in assisted living facilities: A retrospective cohort study and clinical protocol evaluation. Prehosp Emerg Care. 2013;17(1):111.
9. Downloads. (2016.) International Roundtable on Community Paramedicine. Retrieved Oct. 30, 2016, from www.ircp.info.
10. Castillo DJ, Myers JB, Mocko J, Beck EH. Mobile integrated healthcare: Preliminary experience and impact analysis with a medicare advantage population. Journal of Health Economics and Outcomes Research. 2016;4(2):172–187.
11. Survey of patients’ experiences (HCAHPS). (n.d.) Medicare.gov. Retrieved Oct. 31, 2016, from www.medicare.gov/hospitalcompare/Data/Overview.html.
In their own words
From patient outreach to the delivery of clinical care, including in-hospital and pre-discharge visits, Evolution Health’s Florida Outpatient Services Team used various touchpoints to drive patient activation and engagement.
Merlin Underwood, EMT-P
I’ve done just about every type of prehospital EMS there is, including 9-1-1 rescue, interfacility transport, specialty care team transports and critical care transport.
I first heard the term community paramedic two years ago—it wasn’t even called mobile integrated healthcare yet. I knew this was something I wanted to be a part of and that our MIH model would become a major part of the future of non-emergent prehospital healthcare.
Our MCC is in the same location as our dispatch center. This allows the two teams to communicate seamlessly. My role in the system begins after a call has gone through medical triage to make sure the situation isn’t life-
threatening. I’m then dispatched to the patient’s location as a single provider, but I have every possible resource at my fingertips.
Once I’m on scene, I have to bring all of my diagnostic and evaluation skills to bear to determine the best course of action for the patient. If needed, I can communicate with our medical triage officer, a registered nurse, physician assistant, doctor of osteopathy or medical doctor, a pharmacist or a case manager. They’re all available to me 24 hours a day.
Nurse Navigator Victoria Ordunez, LPN
Our MCCs are the hub though which all planned and unplanned care is coordinated. My role is to improve patient experience and outcomes through effective care coordination.
By working with my team members in the field, I’m able to ensure that the right care is delivered to every patient at the right time. I triage patients over the phone, gathering details and vitals to determine care needs. I also interpret the patient’s state through their tone of voice, sensing hesitation or discomfort—a skill I picked up during my experience working with geriatric and mental health patients.
Through this virtual assessment, I can identify the patient’s required level of care. If their situation is emergent, I can dispatch an EMT or paramedic to the patient. In less urgent situations, I can send a nurse or other field provider.
I know the MIH model works because all roles contribute to delivering seamless care. My role is to be the patient’s advocate by working with everyone on the MIH team to provide the best solutions for each individual patient.
Ryun McKenzie, PharmD
The healthcare environment is becoming increasingly complex and compartmentalized, with patients and providers alike finding it difficult to keep track of medications/therapies from multiple specialists often prescribing independently without coordination.
As a clinical pharmacist, I can make interventions that can save lives and empower patients to take control of their medical care, allowing them to stay healthy and safe at home.
My primary role is as a community resource and patient advocate. My goals are to enhance patient access to healthcare, improve health outcomes by providing guidance on safe and cost-effective medications, and I play a critical role in closing the revolving door of hospital readmissions.
I collaborate with nurse navigators and field providers to give the appropriate level of intervention and education to every patient. A significant part of my duty as a pharmacist is to help bridge the therapy gap by providing a central repository of accurate and clinically relevant drug information for all stakeholders.
This involves continuous medication monitoring and reconciliation with the aim of identifying and addressing therapy duplications, untreated indication, sub/supra-therapeutic dosing, significant drug interactions or adverse events, to name a few.
The pharmacy department at Evolution Health exists to service patients, foster positive healthcare relationships, and optimize safety and therapeutic outcomes.
Advanced Practice Provider Amy Dudney, ARNP, FNP-BC
Evolution Health’s MIH model is disrupting one of the most frustrating and expensive patterns plaguing healthcare—unnecessary hospital readmissions.
After years of practicing in EDs and urgent care settings, and seeing countless patients return due to a lack of post-discharge care, I decided to join an MIH team and be a part of the solution. As an MIH advanced practice provider, I help patients manage their chronic conditions after a hospitalization or in the hopes of preventing one altogether. I work with the team at the MCC and in the field to ensure patients receive the appropriate resources to meet their care needs.
Through coordinated efforts with my colleagues, I’m able to manage unplanned care episodes without directing patients to the ED. Whether I’m educating patients on disease management, caring for them through our telemedicine capabilities or implementing chronic care management plans, each day offers unique challenges and rewards.
Most importantly, I’m able to care for patient populations whenever and wherever they need it.
MIH Nurse Coordinator Belena Adkins, RN, BSN, CHPN
Patients and families are often unaware of the resources they need—or are available to them—for improving care and quality of life. This is all too common in traditional healthcare systems in which clinicians are disconnected from other healthcare providers, like pharmacists and social workers.
Our MIH model bridges these gaps using an interprofessional team to coordinate patient care through every stage of their healthcare journey.
As a mobile integrated nurse coordinator, I pair patients with the right resource at the right time. I collaborate not only with internal team members but with patients’ primary care physicians and specialists to schedule timely appointments and guarantee follow-up care.
Reducing hospitalizations is my primary goal and is achieved through consistent assessments and timely intervention. I also focus on empowering patients and caregivers to play an active role in their own care or their loved one’s care by educating them to ask meaningful questions that contribute to their healthcare goals.
With 12 years of hospice and palliative care experience, I can effectively guide the sometimes difficult conversations with patients. It’s that experience that continues to help me identify and fill gaps in care—such as referring a patient to hospice for better end-of-life care or connecting them to a social worker or mental health counselor for improved quality of life. I care for the whole patient, comprehensively, not one symptom or disease at a time.