Nursing in the Community: Using a Mobile Integrated Health Program to Improve Outcomes
Mar. 12, 2020
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.
The hospital initiative has multiple components addressing readmission rates, length of stay and transitions of care. Patients discharged with one of the aforementioned diagnoses or patients considered high-risk for readmission are referred to MIH for post-discharge follow up. During this follow-up visit the advance practice provider will review discharge instructions, provide tailored health education, reconcile medications, and confirm or schedule follow-up appointments. This is in addition to the comprehensive risk assessment. Within this initiative, patients identified with concerns can also be referred by social service and case management for follow up.
The reasons for referrals vary from frequently missed appointments to patients not sounding as they normally do on the phone. MIH also works with the obstetrics department to decrease length of stay by providing follow-up care for postpartum moms with elevated blood pressures. These women are able to be safely discharged one to two days early with prompt MIH follow up and communication with the obstetrics department. The MIH team also provides follow-up care on patients as they are discharged from rehab facilities, personal care homes or skilled nursing facilities back into their home setting; the team provides safety evaluations and ensures patients receive the appropriate home health services.
The Grady 911 communication center uses the medical priority dispatch system to triage incoming calls. Using this system allows each call to be triaged resulting in an emergency medical dispatch code (EMD) based upon the caller’s chief complaint. Grady’s 911 center receives approximately 180,000 calls per year and approximately 40% are non-emergent complaints. This creates a tremendous burden on the 911 system and the emergency room as it fills with patients with non-acute symptomology. In effort to create a multifaceted response system, the MIH team responds to 62 different EMD codes, ranging from back pain to sunburn.
The benefit of this tailored response is in the clinical acumen of the nurse practitioner. Within the past year, MIH responded to over 3,000 911 calls and 44% of those calls were mitigated in the home and did not require transport to the ED. In addition to responding to non-emergent 911 calls, the MIH team also follows up with high utilizers (defined as calling 911 more than five times in a 30-day period) and accepts referrals from the 911 crews in the field, including firefighters and police officers. During these encounters, the nurse practitioner addresses the individual’s chief complaint and completes a comprehensive risk assessment to identify additional barriers or factors impacting the patient’s overall health or access to care.
The third initiative was developed in response to the ongoing opioid crisis. According to the Centers for Disease Control and Prevention, Georgia is one of the states with a statistically significant increase in drug overdose deaths from 2016-2017 (CDC, 2019). With grant funding from the National Association of County and City Health Officials, a post-overdose program was developed, incorporating the use of a peer support specialist (PSS). The PSS is stationed in the ED and as individuals with an opioid overdose-related diagnosis are stabilized, they are able to speak with the individual to identify their wishes in regard to their substance use behavior.
Once enrolled in the program, the individual can be assisted by the PSS, accessing medication-assisted treatment programs, support groups and housing. The program is comprehensive and provides harm reduction strategies to reduce the risk of a fatal overdose. The nurse practitioner is available for consultation if the individual has any medical concerns.
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-BCEMS mobile integrated health practice manager
Grady Health System, Atlanta