Chicago CHF Trial: So Far, So Good for MIH Approach

If hospitals are to avoid penalties for preventable readmissions under the Affordable Care Act, they’ll have to deal with heart failure. The 30-day readmission rate for this vulnerable group of patients approaches 25%, per a study of Medicare data published earlier this year.¹ A little proactive post-discharge home care, one would think, might prune that down.

Emergency docs at the University of Chicago Medicine think so, and to prove it they put together a three-month mobile integrated healthcare trial for their discharged CHF patients that brought together EMS, home health and a number of other players to resolve patients’ problems without returning them to the hospital.

Early returns were promising: Seven weeks in, none of the patients enrolled had required readmission.

“So far it’s been truly successful,” says Lauren Rubinson-Morris, president and CEO of Medical Express Ambulance Service (MedEx), the University of Chicago’s ambulance provider and the project’s EMS arm. “We’ve had no readmissions, and we’ve had positive feedback from the patients, their families and their caregivers. We’re anxious to see what the statistics are at the end. Hopefully we’ll have successful numbers and be able to expand the program to other types of patients.”

For the project, CHF patients discharged from the University of Chicago are taken home by MedEx and tracked with the help of a wireless telemonitor. Home health partner Health Resource Solutions (HRS) delivers the patients’ primary care and education; MedEx is available for emergencies. HRS, MedEx and all other partners—including medical control docs, primary care physicians, cardiologists, nurses, social workers, therapists and pharmacy providers—are accessible through a 24/7 call center created to troubleshoot problems.

CHF patients are particularly vulnerable during the transitional period after the first arrive home, when they can have new meds, new routines and varying degrees of family assistance. That’s a key period for heading off problems.

“One of things we’ve had, for example, is a patient who, when the paramedics got him home, had no medications,” says Jeff Collins, CCEMT-P, MedEx’s operations manager. “Under the old protocol, he’d have just had no medications. Now we’re able to call the home health agency and report that. The home health agency can immediately call the pharmacy, find out what’s going on and get the medications en route. Then they call the paramedics back and say, ‘They’ll be there in two hours.’ The system makes sure the patient has their medications, and this is a prime example of how well it works as a team effort.”

That exemplifies the idea behind mobile integrated healthcare, and the UCM effort is notable for its breadth. Pharmacy partner HomeScript offers home delivery of medications, and telehealth provider Cardiocom contributed a key component with its Commander Flex telemonitor. That wirelessly sends patients’ daily vitals, weight and other data to home health and cardiology personnel, alerting them if values go awry. It’s also a mechanism for educating patients and keeping them engaged in their care, and telemonitoring has been linked to better outcomes.²

In an era where healthcare will increasingly be judged on value, the program is producing higher levels of sastisfaction among patients and their loved ones too.

“One of the unique things about this program is that not only are we collecting objective data, we’re also asking patients’ family members if they found it helpful,” says Alicia Pufundt, RN, MSN, MedEx’s director of critical care. “The overwhelming response from patients and families is that they are finding it helpful for a variety of reasons, including the medication assessments we’re doing, the education that’s occurring, and reviewing their follow-up appointments, making sure they understand those types of things.”

Home Health

EMS systems pursuing mobile integrated healthcare and community paramedicine have sometimes found themselves at odds with home health providers, who may fear infringement on their turf or see EMS as competition for patients. That hasn’t been the case in the Chicago trial. Home health partner HRS welcomed the collaboration.

“Both home healthcare and EMS have valuable skill sets, but I don’t see them conflicting,” says HRS owner Glenn Steigbigel. “I don’t see EMS coming into the home health spectrum and doing things like disease-state management and ongoing patient education and care. They’re very good at providing the emergency, immediate type of service. If a patient has something happen at night, when we can’t easily get a nurse to them, well, maybe we can get an EMS provider out to triage and stabilize that person, and then our nurse can come pick back up the next day.”

Education in the Chicago trial is a group endeavor. MedEx providers deliver materials when they take the patient home, and with care integrated, everyone from the hospital to the bedside provides ongoing direction that’s consistent and cohesive. The bulk of that day to day falls to home health, though it’s not to say EMS couldn’t serve certain educational roles in other types of projects.

“It’s our job to provide strong education for those patients: what heart failure is, why they had it, what their medications are, why it’s necessary to take them, why their diet is important, why it’s necessary to record their weight daily to see if they’re retaining fluid,” says Steigbigel. “That way we can get orders from a physician and adjust their medications as needed. But if we can’t get the patient educated to those type of things, it becomes difficult. They might skip their medication or eat the wrong things; then they’re back in the hospital because they’re retaining fluid and can’t breathe.”

Home health also generally operates during the day, and it’s not always easy to get caregivers to patients with problems during off-hours. With MedEx available, that’s not a concern. And that front-line information crews gather when they first get to patients’ homes is a big benefit to HRS providers later.

“The report the paramedics provide to our office when our nurse is going for the first visit has been a tremendous help,” says Steigbigel. “We serve all socioeconomics of people, so you never know what type of house you might be going into. You don’t know whether the doorbell’s working, or they use a side door, or they went to their daughter’s house and didn’t go home, or who the caregiver or emergency contact might be, or if they have a dog that needs to be locked up. Knowing that kind of stuff helps our nurses feel much more prepared.”

The other big benefit to working together has been familiarity. The worlds of MedEx and HRS hadn’t much overlapped before the CHF collaboration; now the organizations are better acquainted and comfortable working together. They’re looking to partner on other projects in the future.

“Some of the initial anxiety has been dispelled because we’re working so well together,” says Pufundt. “Each of us has individual responsibilities and is working very cohesively.”

FD Involvement

As the CHF trial concludes, an even bigger player is readying to enter the MIH arena: The Chicago Fire Department is weighing what kinds of partnerships and programs it can pursue.
CFD is one of the first big-city departments to formally embrace the MIH concept, but it’s not an odd fit. Firefighters have been involved in prevention for years.

“If someone even just asks us to come in and do a safety check, we’ll do it,” notes Leslee Stein-Spencer, RN, MS, who manages the department’s medical administration and regulatory compliance. “We identify areas to prevent falls. We look at smoke detectors and go door-to-door making those available. So we’re already doing some of these types of things.”

Since the key to MIH is to fill gaps and not duplicate existing services, the department has been collaborating with city partners—for example, its Health and Human Services and senior-services arms—to identify areas that could benefit from intervention. It’s active now with things like fall and lift assistance, and the city already has a 3-1-1 line for well-being checks and other nonemergency needs.

In the same spirit, from 1984 to 2005 the city operated its First Aid Care Team (FACT) program for public housing. Trained team members stationed in developments, often current and former residents, provided basic walk-in care and first response, often delivering initial care before ambulances arrived. They also treated nonemergency cases that didn’t require additional response. Of more than 36,000 requests for help over FACT’s duration, around 27% ended up nontransports. And in the 1990s, FACT also helped execute a successful pediatric immunization program (see sidebar).

“There are many people who call 9-1-1 because they just don’t know what else to do,” says Stein-Spencer. “Maybe they’re just not feeling good and don’t know what it is; maybe they need a blood pressure or blood sugar check. We provide those kinds of services anyway, but without follow-up. It would be nice to look at things like wound-care checks, blood pressure screenings, flu vaccines for seniors—ways to complement services in an urban area where people don’t know where to go or don’t have access to the care that’s there.”

Conclusion

A lot’s been said about finding the right kinds of caregivers for EMS MIH programs—those gifted with compassion and critical thinking rather than just adrenaline junkies. But if MedEx is any example, MIH will have wide appeal among medics frustrated with the inadequacies of current healthcare systems.

“It was a pleasant surprise how much our paramedics bought into it,” says Collins. “They like that they can transport somebody home, and if they identify a problem, they have an outlet. They have home health and live medical control they can call, and they have an avenue to get something done for the patient. In the past we didn’t always have that available.”

If the CHF program is a success, there’s ground for expansion. Orthopedic patients have transitional needs amenable to this kind of structured care; asthmatics and diabetics are also on the short list. And demonstrating success may generate support from payers that will be important to sustaining these kinds of efforts in the future.

But first comes showing all this work can save money.

“That’s really one of the purposes of a pilot like this, to establish the actual value behind it,” says Michael Pieroni, MedEx’s director of operations. “Before, if something went wrong, the patient went right to the highest level of care, bypassing all the short-term answers we’re using in the pilot program. The whole point is to develop routines to avoid the highest-cost solution, and this program offers cost-effective alternatives. We think that’s exactly what the data will show.”

References

1. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA, 2013; 309(4): 355-363.

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