CORONAVIRUS (COVID-19) RESOURCE CENTER Read More

Charles County Mobile Integrated Healthcare

State: MD Type: Model Practice Year: 2019

Charles County, Maryland is a largely rural jurisdiction located 23 miles south of Washington, D.C. It is one of five Maryland counties, which are part of the Washington, DC-MD-VA metropolitan area. At 458 square miles, Charles County is the eighth largest of Maryland's twenty-four counties. The current 2017 population for Charles County is 159,700. Charles County, Maryland is a diverse community with minorities comprising nearly 56% of the county population. The mission of the Charles County Department of Health (CCDOH) is to protect, promote, and improve the health and well being of its citizens. The CCDOH is a local entity of the Maryland Department of Health. The health department currently employs a diverse and well educated staff of approximately 275 employees. The health department is adept at monitoring the demographics of the county and tailoring programs to meet the changing needs of the county. The CCDOH has excellent partnerships with other county agencies for program collaboration. The Charles County Mobile Integrated Healthcare (MIH) Team is an innovative public/private partnership between the Charles County Department of Health, the Charles County Department of Emergency Services, and the University of Maryland Charles Regional Medical Center. MIH is an integration of three agencies for one common goal. The pairing of emergency medical services and public health practice is instrumental to the success of the MIH program. The MIH team consists of a paramedic, a community health nurse, and a community health worker. This team is closing the healthcare loop and ensuring the best outcomes for its clients. During an initial home visit, the MIH team assesses the client's vital signs, reviews discharge paperwork, evaluates compliance with discharge instructions, completes a medication evaluation/reconciliation, conducts an environmental scan of the home for safety issues, and provides health education and chronic disease self management information. When appropriate, they return to correct any issues identified in the environmental scan, such as installing new smoke detectors. They work diligently to educate and empower clients to take control of their own health. The team has developed a binder for each client. It is full of information specific to their health conditions. It also contains information on available county services. Clients take their binders to their doctor and specialist appointments. They provide them with self management tools to monitor their own health, such as blood pressure monitors and scales. They have given them pocket calendars to write down their appointments. They have sat down with clients and gone through all of their medication bottles and helped them to get organized with daily medical organizers. The MIH team helps to connect clients with needed services and resources within the county. They have spent hours on hold with insurance companies to talk to someone about covered services. They have completed necessary paperwork to get people signed up for medical assistance transportation. They communicate with physicians to get forms signed and returned. Many of the clients could not navigate the system without the help of the MIH team. The program is tracking the number of ED visits and inpatient admissions by program participants, as a reduction in hospital use is a key outcome measure to document program impact. At the time of data analysis, the MIH team had seen a total of 50 clients. In the 3 months prior to MIH participation, these 50 patients had a total of 68 visits to the local hospital emergency department. After MIH, the number of ED visits among participants dropped 60% to a total of 27 ED visits. The number of inpatient admissions dropped 57% from a total of 37 inpatient admissions 3 months prior to MIH to 16 inpatient admissions. The number of 30 day readmissions dropped from 7 to 1. EMS call volume reduced by 48%. From May 1, 2017-October 31, 2017, the MIH clients made 143 calls to EMS. From November 1, 2017 to April 1, 2018, the number of EMS calls dropped to 75 calls. 29 out of 46 MIH saw a reduction in EMS utilization after enrollment (63%). Using the average costs for an inpatient admission and an emergency department visit, it is estimated that the MIH program saved nearly $500,000 in its first year of implementation. The efforts of this team impact the county hospital's need to reduce utilization and costs in the Maryland Medicare All-Payer Model. The team also saves the Charles County Government due to the reduction in non-emergent hospital transport. For more information on the Charles County Department of Health, visit our website at charlescountyhealth.org.
Statement of the problem/public health issue. The Charles County Department of Health, in collaboration with the University of Maryland Charles Regional Medical Center and the Charles County Department of Emergency Services, established a Mobile Integrated Healthcare (MIH) project to address the health/social determinants leading to repeated use of emergent care. The delivery model of Mobile Integrated Healthcare aims to address the needs of patients that do not qualify for home health assistance yet require some transitional oversight between discharge from a healthcare facility and resuming independent self-maintenance. The patients for this project are those deemed high risk for readmission based on their discharge diagnosis or those who are currently high utilizers of the emergency department or emergency medical services. What target population is affected by problem? (please include relevant demographics) What is the target population size? With the increase in overall population, Charles County has also experienced an increase in the 65 years and older population or the "baby boomer" generation. The percent of the population 65 years and older has increased from 9.1% in 2010 to 10.3% in 2014. Among the 65+ population in Charles County, 36.2% report having a disability. As this population ages and continues to live longer than previous generations, they place a burden on the healthcare system to deal with aging and chronic disease symptoms and complications. Due to a shortage of primary care providers in Charles County, some must seek care from acute care settings such as the hospital to address their healthcare needs. An initial analysis of University of Maryland Charles Regional Medical Center ED data was performed from January 1,2015 through March 26, 2015. A total of 243 emergency department visits were conducted among 29 high utilizers to the University of Maryland Charles Regional Medical Center. The criteria for this search was any hospital patient with 6 or more visits to the emergency department in the three month period. Emergent care is the most expensive means of health care, and this small group of utilizers place a costly and time consuming burden on the entire health system in Charles County. The average cost of an emergency department visit in the United States is $1233 plus overhead. According to the Chief Financial Officer at the University of Maryland Charles Regional Medical Center, the cost in Charles County is similar to the national average. However, those individuals frequenting the emergency department often have complicated chronic conditions that require additional, costly testing. A second analysis of ED utilization was conducted in December 2015 using the time frame January 1-November 30, 2015. The criteria for inclusion was any patient with 20 or more visits to the emergency department during the specified time period. The data was queried by the transition nurse case manager using the HSCRC database. From January 1, 2015 through November 30,2015, a total of 20 patients made at least 20 visits or more to the University of Maryland Charles Regional Medical Center Emergency Department. They accounted for a total of 643 visits. That is an average of 32 visits per patient. Visit counts ranged from 20 visits to 124 visits per patient in the 11 month time frame. The majority of the patients had either Medicaid (55%) or Medicare (35%) as their primary health insurance. The average number of visits among patients with Medicaid was 25 visits per patient. The average number of visits among patients with Medicare was 82 visits per patient. Managing their conditions in the primary care and home setting could lead to a reduction in hospital visits and a needed reduction in the 30-day readmissions rate to avoid penalties. Most of the high utilizers were discharged to their homes for self care after they have been treated in the acute hospital setting. The most commonly reported reasons for their visits included pain, shortness of breath/trouble breathing, chest pain, and behavioral health conditions. These patients could greatly benefit from community resources to help them self manage their disease processes and how changes to the home can improve their health. Top reasons for ED Visits Count (#) Percent of Total Visits (%) Pain 223 35% Asthma/Shortness of Breath/Trouble Breathing 72 12% Chest Pain 67 10% Behavioral Health (Mental Health and Substance Use) 55 9% Abdominal Pain 47 7% Medication Refills 42 7% Headache 23 4% An examination was conducted of the In-patient Risk-adjusted 30-day Readmissions Data for Charles Regional Medical Center from January 1 through October 31,2015. 55% are Medicare recipients (377 out of 692). 62% of patients were discharged to home for self care without home health (431 out of 692). Only 16% were discharged to home under the care of a organized home health service. The remaining discharges were released to a nursing home, long term care facility, rehabilitation center, or hospice. The top principal diagnoses among in-patient 30 day readmissions were Septicemia, chronic bronchitis; pneumonia, organism not otherwise specified; and urinary tract infection. The hospital 30 day readmissions rate was 11.53% in 2016. The projected rate set by Medicare to avoid penalty is 11.7%. Any reductions in readmissions through this program had the potential to greatly impact this rate and help the hospital to avoid penalty. Qualitative data on the factors leading to high utilization were discussed in key informant interviews with hospital nurse case managers and county EMS personnel. Speaking with staff, it was established that social, geographic, and health factors, such as isolation and lack of support services, can lead to an increase in 911 calls and high utilization of hospital and EMS services among the target population. Elderly living alone may call 911 even though they are really in need of social interaction and could benefit from community services such as senior center activities. Some residents call 911 because they are in need of routine healthcare but do not have the transportation to their primary care provider located 25 miles away in Waldorf. Hospital staff have been told by ED high utilizers that they continue to come to the hospital for all of their care because that is where they are comfortable. Hospital staff also expressed concern over the home environment of some of their patients. The hospital is only treating the patient's acute symptoms, but if their home environment is unhealthy, they will continue to experience symptoms. Lastly, patients may need assistance with understanding their discharge or physician instructions upon discharge from the hospital. Additional assistance in navigating the health care system and in connecting to available community and social services could improve the well-being and health of these patients. What percentage did you reach? What has been done in the past to address the problem? Looking at the number of people identified as high utilizers (20 or more ED visits) before implementation (N=20), our goal was to provide services to 20 people in Year 1. The MIH team was able to far surpass this number in its first year of implementation. There were a total of 75 participants in Year 1. Other population health level initiatives have been instituted by the University of Maryland Charles Regional Medical Center before the implementation of MIH. They established a Population Health Program, created a palliative care program, and started an Access to Care Coalition to close the look with long term care facilities and hospital and community agency staff. They also have a set of nurse case managers who are able to provide some care coordination to high utilizers of hospital care. They make phone calls, set up primary care appointments, assist with transportation. Why is the current/proposed practice better? Is current practice innovative? How so/explain? Is it new to the field of public health? Is it a creative use of existing tool or practice? While a person is in the hospital, the staff are focused on the acute situation. They are not aware of any other environmental or social factors that may be directing that person's status of health. The Charles County Mobile Integrated Healthcare Team is able to go into the home and access that situation. They can provide suggestions on how to improve the home and eliminate safety concerns. They are able to assess the patient in a home setting, educate them on their disease processes, and provide them with referral to identified needs for service. The idea of Mobile Integrated Healthcare is not a novel idea; however, the integration of public health into community paramedicine is a new idea. Most Mobile Integrated Healthcare programs or Community Paramedicine programs falls under Emergency Medical Services or Fire and Rescue Squads. For Charles County, Maryland, the program is run by the local health department, emergency services, and local hospital together. Additionally, the structure of the Charles County MIH team is unique from most MIH programs. The local health department felt it was important to include a community health nurse and a community health worker alongside the paramedic. We know that the community trusts the paramedic in their home; however, there are years of evidence to support the effectiveness of public health nursing within the home. Lastly, community health workers are wonderful instruments in educating the public on health by using a person who looks like you and talks like you. It is important that people can identify with them and trust them when they are presenting them with suggestions for improving their health and wellbeing. What tool or practice did you use in an original way to create your practice? (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, a tool from NACCHO's Toolbox etc.) Objectives and Goals for the Charles County Mobile Integrated Healthcare program were chosen using the Maryland State Health Improvement Process measures and the Healthy People 2020 objectives. Mobile Integrated Healthcare draws upon evidence-based practices using multidisciplinary and interprofessional teams to support healthcare delivery innovation. Is the current practice evidence-based? If yes, provide references (Examples of evidence-based guidelines include the Guide to Community Preventive Services, MMWR Recommendations and Reports, National Guideline Clearinghouses, and the USPSTF Recommendations.) The Mobile Integrated Healthcare Program is modeled after the care management and team-based care models recommended in the Guide to Community Preventive Services.
Goal(s) and objectives of practice Expected improved outcomes for the target population. 1. Decrease the percentage of ED visits and 911 system calls among participants by 25%. 2. Increase the number of participants who visit their primary care provider twice a year for routine care. 3. Increase health literacy by educating participants on prevention/management of their disease processes. 4. Make at least one referral per participant to a needed community, health, or social service. 5. Give people the tools to self manage their disease processes. Additional Intermediate Objectives: -Recruit 10 hospital high utilizers to participate in the program (5 in the first half of Year 1 and 5 in the second half of Year 1) -Recruit 5 EMS high utilizers to participate in the program -Recruit 5 participants to the program from partnering community agencies (Community Services, Social Services, AERS, etc) -Decrease the average number of ED visits among high utilizers from 32 to 24 visits per patient. -Work with hospital finance department to determine cost savings related to decrease hospital and ED usage among participants Primary Long Term Outcome: A reduction in the hospital readmission rate to the Medicare all cause, all payer readmission rate of 10.39%. Secondary Long Term Objective Outcome: A 10% reduction in the EMS transport rate due to less usage among high utilizers for non-emergent transport. What did you do to achieve the goals and objectives? Steps taken to implement the program From August 2017 to October 2018, the Charles County MIHealth program served a total of 76 clients. This is beyond the goal of 60 people that we set for the entire 3 years of the funding cycle. Some clients have remained in the program. Many have been successfully discharged. A few have been discharged due to non-compliance, but we hope that they have gained information and been connected to services that they previously did not have. During an initial home visit, the MIH team assesses the client's vital signs, reviews discharge paperwork, evaluates compliance with discharge instructions, completes a medication evaluation/reconciliation, conducts an environmental scan of the home for safety issues, and provides health education and chronic disease self management information. When appropriate, they return to correct any issues identified in the environmental scan, such as installing new smoke detectors. They work diligently to educate and empower clients to take control of their own health. The team has developed a binder for each client. It is full of information specific to their health conditions. It also contains information on available county services. Clients take their binders to their doctor and specialist appointments. They provide them with self management tools to monitor their own health, such as blood pressure monitors and scales. They have given them pocket calendars to write down their appointments. They have sat down with clients and gone through all of their medication bottles and helped them to get organized with daily medical organizers. The MIH team helps to connect clients with needed services and resources within the county. They have spent hours on hold with insurance companies to talk to someone about covered services. They have completed necessary paperwork to get people signed up for medical assistance transportation. They communicate with physicians to get forms signed and returned. Many of the clients could not navigate the system without the help of the MIH team. Patient recruitment and referrals have mostly come from the hospital and EMS. In September 2018, MIH started Phase 3 of the referral process. The program is now referring clients from Health Partners Inc, a primary care and dental clinic located in Waldorf and Nanjemoy. In November, MIH also began accepting referrals from Dr Childress, a primary care doctor practicing under the umbrella of the University of Maryland Medical System in La Plata, MD. MIHealth will begin accepting referrals from the Charles County Office on Aging starting December 1, 2018. A total of 47 home visits were conducted in the past 6 months. Many of the participant encounters (n=186) had to occur in other locations. Some clients were homeless, so they met the team at a secure location such as McDonalds or Walmart. Additionally, some of the clients needed assistance with medical appointments because they did not understand the doctor's instructions. Therefore, the team accompanied them so they could speak to the doctor and then educate the clients. A lot of contact with clients is done over the phone or by email. A total of 577 encounters occurred in this manner. An additional 307 phone calls or emails were made by the MIHealth team on behalf of the clients. This accounts for 884 phone or email contacts. 2a) # program participant home visits 47 2b) # of face-to-face program participant encounters in other locations (health department, doctor etc) 186 2c) # of program participant encounters by phone or email 577 2d) # of phone or email to outside resources 307 Any criteria for who was selected to receive the practice (if applicable)? Appropriate candidates must be: Must be: ?18 years of age, or older (and) ?Charles County resident (and) ?1 or more chronic health condition *ALL 3 MUST APPLY* Eligibility for high utilizers of emergent care: 6 or more visits to the ED in 3 months or a LACE score greater than 12 (high risk of hospital readmission) 6 or more calls to EMS in 3 months Referrals from primary care or the Area Office on Aging must display one (or more) of the following: 2 missed appointments/no-show's to scheduled appointments (and/or) Have not followed up with recommended specialists/agencies pertaining to health needs (and/or) Poor medication adherence What was the timeframe for the practice where other stakeholders involved? What was their role in the planning and implementation process? What does the LHD do to foster collaboration with community stakeholders? Describe the relationship(s) and how it furthers the practice goal(s) The other stakeholders have been involved since the inception of the program 3 years ago and have played an active role in the development and implementation of the MIH program. All stakeholders continue to work together for the successful implementation and expansion of this program. Funding for this project ends April 30, 2020; however, the 3 partnering agencies (local health department, local hospital, and EMS) will work in the future to continue the same level of program efforts after initial funding has been exhausted. The partner agencies each have a finzncial investment into this program as well as a role in the implementation. The program would not run without the participation of all organizations. The hospital provides significant funds to cover the cost of the paramedic. They provide the majority of the referrals to the program through their nurse case managers. They also assist with data collection and analysis of client medical records. Emergency Services is responsible for the paramedic. Additionally, they provide an outfitted vehicle for the program as well as all medical equipment and supplies. The health department is responsible for the community health nurse and the community health worker. All MIH staff are housed at the health department and cubicles, computers, phones, and office supplies are provided in-kind. Staff supervision, program oversight and evaluation are also provided in-kind by the health department. Any start up or in-kind costs and funding services associated with this practice? Please provide actual data, if possible. Otherwise, provide an estimate of start-up costs/ budget breakdown. Funding for this program was secured from the Maryland Community Health Resources Commission. The grant was awarded for $400,000 over 3 years. The University of Maryland Charles Regional Medical Center is contributing $150,000 for 3 years to the program as well as staff time for referral and data analysis in-kind. They also provide needed supplies such as bus passes and scales when needed. The Department of Emergency Services have provided a vehicle for the program. It is solely for this program and has been outfitted for their needs. All medical equipment,supplies, and uniforms are also provided in-kind. The Department of Health is the adminstrator of the grant funds. General oversight of the staff and program are provided in-kind by an epidemiologist from the health department. Additionally, the office space and supplies are provided in-kind for MIH staff.
In the 3 months prior to MIHealth participation, these 45 patients had a total of 79 visits to the CRMC emergency department. After MIHealth, the number of ED visits among participants has dropped 61% to a total of 31 ED visits. The number of inpatient admissions dropped 76% from a total of 45 inpatient admissions 3 months prior to MIHealth to 11 inpatient admissions 3 months after MIH enrollment. The number of 30 day readmissions dropped from 10 to 0. There have been some remarkable reductions in ED usage among MIHealth clients. However, there are medical emergencies when clients need EMS and need to be seen or admitted to the hospital. On 3 separate occasions, the MIHealth team was able to access the patient and determine that they needed to call 911 for assistance. Those patients were sent to the ED and later admitted for treatment. Additionally, the program has had several clients who have passed away during this time period. Many of them required inpatient care after the hospital before their time of death. From May 1, 2018 to October 31, 2018, there were a total of 73 ED visits, 21 inpatient admissions, and 0 30-day readmissions among MIHealth active participants. This is a reduction from the last reporting period when there were 103 ED visits, 24 inpatient admissions, and 2 30-day readmissions among MIHealth active participants. EMS call volume reduced by 39% from pre and post MIH participation. Looking at the data for active patients, they had 118 911 calls in the 3 months prior to their MIH enrollment date. Since the time of MIH enrollment, there have been 72 calls to 911 from MIHealth participants. One client had 14 calls to 911 in the 3 months prior to MIH enrollment. In the 15 months that the client has participated in MIH, they have not called 911 once. From November 1, 2017 to April 1, 2018, the number of EMS calls among MIH participants was 75 calls. From May 1, 2018-October 31, 2018, the number of 911 calls among MIHealth clients remained low at 77 calls to EMS. 25 out of 45 MIHealth saw a reduction in EMS utilization after enrollment (55%). Ten stayed the same; this was mostly due to low to no call volume before MIH participation. Intermediate Objectives: -Recruit 10 hospital high utilizers to participate in the program each year (5 in the first half of Year 1 and 5 in the second half of Year 1) A total of 53 high utilizers were recruited from the hospital and consented to participate in the MIHealth Program. -Recruit 5 EMS high utilizers to participate in the program A total of 23 high utilizers were recruited from EMS and consented to participate in the MIHealth Program. -Recruit 5 participants to the program from partnering community agencies (Community Services, Social Services, AERS, etc) Phase 3 with recruitment from other agencies including Health Partners inc. Clinic, Dr Childress, and the Charles County Office on Aging did not begin until Fall 2018. We plan to receive 40 referrals from the Office on Aging between December 1, 2018 and June 30, 2018. We will continue working on the protocol for receiving referrals from health department programs and social services. That phase will begin in Spring-Summer 2019. -Work with hospital finance department to determine cost savings related to decrease hospital and ED usage among participants Using the average costs for an inpatient admission and an emergency department visit, it is estimated that the MIH program has saved $375,000 in its first year of implementation. Long Term Objectives: Primary Long Term Outcome: A reduction in the hospital readmission rate to the Medicare all cause, all payer readmission rate of 10.39%. The University of Maryland Charles Regional Medical Center's readmission rate for Calendar Year to Date 2018 is at 9.83%., below the pre-determined goal of 10.39%. The original hospital readmission rate was 11.5%. Secondary Long Term Objective Outcome: A 10% reduction in the EMS transport rate due to less usage among high utilizers for non-emergent transport. There was a 39% reduction in EMS call volume among MIHealth participants. Data is collected on emergency department visits and hospitalizations by querying the hospital electronic health records of all MIH participants. We are also using the state's health information exchange, CRISP, to receive hospital encounter notifications in real time. Data on 911 calls and EMS transports are queried for each MIH participant using the state EMS server, eMeds, the quality assurance officer for Charles County Emergency Services. All other data is collected by MIH team staff using an Excel spreadsheet. No modifications have been made to the practice as a result of data findings.
Many community programs have long waiting lists such as Adult Evaluation and Review Services. There are some complicated patients, such as those on dialysis, that affect the hospital readmission and high utilization rates but are not necessarily appropriate for MIH services.There are not any social determinants that can be changed to affect their emergent care utilization. Cost of medications are beyond what elderly on a fixed budget can afford. This leads to repeat health crises and use of inappropriate and expensive forms of care. Reduction of food stamp allowance is difficult for those with strict diets due to hypertension and/or diabetes. Transportation, especially those without Medicaid and those who are bedbound. Sometimes, EMS transport is their only alternative. Lessons learned in relation to partner collaboration. (if applicable) A memorandum of understanding with 3 separate agencies can be a nightmare. It is so important to start a draft as early as possible. Keep all partnering agencies abreast of the program successes and challenges through every step of the process. It is better to have them involved in the solutions and in the opportunities for praise. Did you do a cost/benefit analysis? If so, describe. Using the average costs for an inpatient admission and an emergency department visit, it is estimated that the MIH program has saved the hospital $375,000 in its first year of implementation. For every dollar spent on MIH, the partner agencies have saved $2.50. Is there sufficient stakeholder commitment to sustain the practice? Describe sustainability plans. All agencies are financially invested in this program. The hospital has already given $100,000 to EMS for Years 1 and 2 to help cover the cost of the paramedic and supplies. They will continue to provide this funding each year. Each organization is committed to the success of this program and will continue to find ways to fund it after initial funding has been exhausted. Efforts are already underway for alternative funding sources. With the help of CRISP, the state's health information exchange, we hope to show both the University of Maryland Charles Regional Medical Center and the Charles County Government how much we have saved by investing in a proactive program like MIH instead of allocating more resources to react to the increased volume of EMS transports and ED visits. All 3 organizations are committed to the sustainability of this program if it is proven to be successful. Additionally, John Filer, Chief of EMS, and our county state senator, Mac Middleton, have worked on state legislation to bill for MIH services. The bill did not pass this session, but a working group has been established. Their findings and report will be done by the beginning of 2019 so that legislation on MIH billing can move forward. We were able to leverage an additional $15,475 from the Charles County Area Office on Aging to provide MIHealth team visits and care coordination to individuals on their Maryland Access Point waiting list. The MIHealth team has agreed to accept up to 40 referrals from December 1,2018 to June 30, 2019. The Office on Aging will also provide us with supplies for clients such as automated medication organizers, bed scales, blood pressure cuffs, scales, and other technology-assisted devices for the aging population.
E-Mail from NACCHO