Chicago MIH Effort Targets CHF Patients

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Major cities are home to some of the most medically underserved people you’ll find, and even their suburbs contain plenty of big-ticket health-system utilizers who can benefit from mobile healthcare types of services. An ambitious effort in the Chicago area aims to demonstrate that benefit for one common group of patients.

The project focuses on preventing hospital readmissions among sufferers of congestive heart failure. The participating EMS agency is Skokie-based Medical Express, or MedEx. Other players include the University of Chicago Medicine; Health Resource Solutions (HRS), a home healthcare provider; Allscripts, which provided an integrated electronic health record; Cardiocom, which provides remote telemonitoring; and HomeScript Pharmacy, which delivers medications to patients.

CHF patients discharged from the University of Chicago are taken home by MedEx and tracked by caregivers with the help of a wireless telemonitor. HRS provides ongoing education and care as needed, with EMS available for emergencies. MedEx and other MIHP partners are reachable through a 24/7 call center, which integrates and deploys the entire range of mobile healthcare players including medical direction, cardiologists, primary care physicians, nurses, social workers, home health providers, therapists, advanced practice nurses and pharmacists.

“They can all be brought together in real time to coordinate care by paramedics, and whatever the need is, they can troubleshoot things,” says Eric Beck, DO, EMS medical director for the city of Chicago and assistant professor at the University of Chicago. “This is most important during that transitional period, when they’re just getting home. Say they don’t have their diuretic, or they couldn’t afford it, or their family forgot to pick it up. The paramedics call in, we dispatch the resource, and the meds get delivered to the home. So we use the call center to solve whatever problems are identified by the paramedics during the transition home.”

The arrangement illustrates the inclusive horizontal nature of mobile integrated healthcare. As compared to more traditional community paramedicine approaches in which primarily paramedics are used in expanded nonemergency roles, MIHP offers a systems approach, involving the full spectrum of a community’s providers, resources and infrastructure in a coordinated, goal-directed manner. This model delivers better-integrated and more-comprehensive care. With the ongoing changes in healthcare, and coinciding with this project, MedEx created a new division, MedEx Integrated Healthcare Services (www.medexamb911.com).

A key component is the Commander Flex telemonitor from Cardiocom, which transmits the patient’s daily vitals, weight, and other data back to the home health and cardiology teams. If various predetermined thresholds are exceeded, it prompts intervention. It also delivers heart failure education and keeps patients engaged in their care. “We know from the home-health literature,” notes Beck, “that if you have patients being intensely case-managed with telemonitoring, they do better. It can really help enrich the surveillance and care coordination for the population being managed.”¹

The CHF pilot isn’t the only mobile integrated healthcare undertaking in the works in Chicago; the Chicago Fire Department (CFD) is getting involved too. Details of CFD’s new efforts are still being worked out, but it has a history with MIHP-type activities: Back in the 1990s, department EMT-Bs executed a successful outreach program in inner-city housing projects that led to a significant increase in childhood immunization rates.²

That experience has leaders supportive now, and further impetus comes directly from Mayor Rahm Emanuel, a big believer in the MIHP concept. “Mayor Emanuel is committed to improving service delivery through innovation,” said Michael Negron, his innovation chief, in an August statement. “Several cities have reported early successes with the mobile integrated healthcare approach, and we are working with our fire department to explore its potential application to Chicago.” MIHP stakeholder meetings and community needs assessment dialog is ongoing at a city-wide level.

Meanwhile, the MedEx trial will run through the end of October. It’s a modest effort with which to start, but one designed to provide valuable proof of concept with a population that’s basically low-hanging medical fruit.

“I think the key to both of these initiatives is that we have started small, focusing on the health needs for a defined population,” says Beck. “We see this as a test of change, with heavy process-mapping and refinement–it’s very iterative. And until we have something that actually demonstrates value and an improvement in outcomes, we shouldn’t go forward. Everyone’s excited, everyone’s motivated, but we’re being very deliberate, very thoughtful in design, so that we have the best chance to be successful.”

For more on Chicago’s new MIH efforts, see the November issue of EMS World.

References

1. Desai AS, Stevenson LW. Connecting the Circle from Home to Heart Failure Disease Management. N Engl J of Med, 2010 10.1056/nejme1011769.

2. Goldstein KP, Lauderdale DS, Glushak C, Walter J, Daum RS. Immunization outreach in an inner-city housing development: Reminder—recall on foot. Pediatrics, 1999 Dec; 104(6): e69.