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Nursing in the Community: Using a Mobile Integrated Health Program to Improve Outcomes

As with most safety net hospitals, a large percentage of the patient population treated at Grady Health System in Atlanta has multiple comorbidities compounded by social determinants of health directly impacting access and utilization of local health care services (Bell, Turbow, George, & Ali, 2017). The mobile integrated health (MIH) program utilizes the expertise of a nurse practitioner to provide quality care, identify patient needs and gaps in care while connecting patients with the most appropriate resource.

Encounters with two patients

Ms. Jones is a patient with whom those who have worked in the hospital setting are all too familiar. She is seen often in the emergency department (ED) for a variety of complaints. She is seen even more by our emergency medical service (EMS) counterparts for her numerous calls to 911. The majority of the encounters are not an emergency and do not require treatment in the acute care setting. However, after a 911 call, off to the ED she goes. Arriving there, staff are taking care of more acute patients despite the nursing shortage that continues to impact care delivery. Since Ms. Jones is stable and her back pain is chronic rather than acute, she sits waiting on pain medication. Once she is seen, the resident discharges her with advice to follow up with her primary care provider (PCP) or an orthopedist. Ms. Jones does not have a PCP nor does she have access to transportation, which is why she calls 911 when she has what she considers to be a “medical need.”

Then we meet Mr. Smith, who has a long history of congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). He has been hospitalized 10 times in the past 12 months for acute CHF. His wife of 43 years passed away 16 months ago. He keeps the majority of his cardiology and pulmonology appointments, but he still ends up in the hospital about every six to eight weeks. Patients with stories similar to these are all too familiar and unfortunately contribute to poor health outcomes, high ED and 911 utilization, avoidable admissions, readmission penalties and fragmentation of care.

Bringing care to the patient

There are benefits and challenges to operating a hospital-based EMS system. As the 911 provider for the city of Atlanta and Fulton County, Grady Health System is in a unique position. Operating a hospital in a large metropolitan area, it’s important that the health system lower readmission rates for conditions such as heart failure, pneumonia, acute myocardial infraction, COPD and status post coronary artery bypass graft.

Challenged with providing care to the most vulnerable members of the population, in January 2013 an innovative MIH care delivery model was born. Designed to meet both patient and organizational needs, the program’s team is comprised of a nurse practitioner and an emergency medical technician (EMT). The team meets patients in their homes, traveling in an SUV fully equipped for medical first response; the vehicle contains a cardiac monitor and a device for point-of-care labs.

The EMT is a valued partner, skilled at scene safety and situational awareness, recognizing the inherent safety concerns when providing care in the field. All MIH visits include a comprehensive risk assessment with the intention of identifying gaps and coordinating care to break the patient’s cycle of seeking emergency care, improving health outcomes and changing resource utilization. As barriers or gaps in care are identified, interdisciplinary collaboration occurs with case management and social work to facilitate connections with community organizations and internal resources. 

CURRENTLY, THREE ACTIVE INITIATIVES ARE IN OPERATION UNDER THE GRADY MIH UMBRELLA.
HOSPITAL +
911 +
POST-OVERDOSE PROGRAM +

Two patients: The rest of the story

Ms. Jones was referred to MIH by one of the 911 crews who transported her to the hospital. The paramedic was familiar with MIH and recognized this patient needed additional support. During her MIH visit, the nurse practitioner found that Ms. Jones had not seen her PCP or an orthopedist for nearly year. Ms. Jones reported her pain was so severe that she was scared to drive and has not been able to keep her appointments. Her children are grown and supportive, but do not live in Atlanta. She does not want to seem like a bother, so she has not been very honest with them about the reality of her condition. She admits that she is not eating well, as she has a hard time standing up to cook. After her visit Ms.

Jones was scheduled with a PCP and transportation was arranged. Prior to the appointment, MIH informed the PCP team of Ms. Jones’ needs so they could be addressed during her visit. Ms. Jones was able to keep her appointment and received an order for home physical therapy and an orthopedics referral for follow up. Case management staff assisted with Meals on Wheels to improve her diet until she is more mobile. Since transportation was recognized as a barrier for Ms. Jones, transportation was arranged to her orthopedic appointment. Ms. Jones is doing much better and has not called 911 since her MIH visit.

Mr. Smith was referred to MIH as a post-discharge patient with CHF. During his MIH visit, he told the nurse practitioner that his wife passed away about 16 months ago and that she used to take care of him. He admits that it has been hard for him to do so and that is probably why he ends up in the hospital so often. He also admits that he is probably depressed because he does not like living alone. This information was relayed to his case manager and a follow-up appointment with his PCP was scheduled. After a few months, Mr. Jones transitioned into an assisted living community where he reports he is much happier.

Results

Program effectiveness is measured by the 30-day readmission rate for patients seen by the MIH team within 14 days of discharge and the percent of patients diverted from the ED and mitigated in the home setting after calling 911. In 2019, the MIH team provided care to more than 300 post-discharge patients and only 2.95% were readmitted. With these promising results, new initiatives are being created to allow increased utilization of the MIH team to address care gaps in the home setting to reduce readmissions, prevent admissions and improve health outcomes.

Programs similar to MIH will become more prevalent as health care systems continue to look for innovative strategies to provide quality care and maintain fiscal stability. The skill set of the advanced practice provider allows versatility for inclusion into a variety of different areas to improve patient care and health outcomes. As we continue to look at the needs of the Grady service area, the MIH program will continue to evolve to meet both patient and organizational needs.

References
Bell, J., Turbow, S., George, M., & Ali, M. K. (2017). Factors associated with high-utilization in a safety net setting. BMC Health Services Research, 17, 1–9. Retrieved from https://doi.org/10.1186/s12913-017-2209-0
Centers for Disease Control and Prevention. (2019). Drug Overdose Deaths. Retrieved from https://www.cdc.gov/drugoverdose/data/statedeaths.html

About the Authors

Shara Mayberry, DNP, MPH, ANP-BC
EMS mobile integrated health practice manager
Grady Health System, Atlanta

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