Mobile Integrated Healthcare Part 3: Health Care Innovation Grant Recipients Making Progress

Ed's Note: Registration is now open for the MIH Summit, April 28, Washington, D.C. Visit MIHSummit.com.

This past summer, the second round of Health Care Innovation Awards were distributed by the Centers for Medicare & Medicaid Services (CMS). These are funding grants to applicants who are implementing the most compelling new ideas to deliver better health, improved care and lower costs to people enrolled in Medicare, Medicaid and the Children’s Health Insurance Program (CHIP), particularly those with the highest healthcare needs.

Following is an update on two of these recent grantees, the Mesa (AZ) Fire and Medical Department and the Mount Sinai Medical Center (NY), which include aspects of mobile integrated healthcare (MIH) in their grant programs.

City of Mesa Fire and Medical Department

Project Title: “Community Care Response Initiative”
Geographic Reach: Arizona
Estimated Funding Amount: $12,515,727

The City of Mesa Fire and Medical Department received an award to test a model that offers new comprehensive delivery systems and addresses the impact of chronic disease, falls prevention, self-management skills and medication adherence.

The model aims to reduce high-risk patient returns post-discharge, and the treat and referral of low-acuity patients from the use of the 9-1-1 systems and the emergency department. The program provides low acuity patients with on-site evaluation and treatment; and/or refers patients to more appropriate services, which reduce duplication efforts between emergency rooms and private physician providers. High-risk patients receive follow up evaluations after discharge to reduce the incidence of readmission.

Disease preventative services are provided, including immunizations, falls prevention, home safety inspection and the safe use of prescribed medications. The Community Care Response Initiative consists of four units operating 24 hours per day, 365 days per year throughout the Mesa area. Also provided is a physician extender unit—a modified ambulance that takes the team to perform low acuity services or post discharge hospital follow-up. The services provided by this unit are similar to services provided by an urgent care: in depth patient evaluations, behavioral health evaluations, suturing, minor trauma evaluations, cardiac diagnostic capabilities, pain management, prescription services, immunizations, health education, referral services, primary care consultations, sepsis evaluations, post discharge follow ups and minor diagnostic testing.

According to Gary Smith, MD, MMM, FAAFP, “Mesa Fire and Medical Department is excited to report that we have experienced great success in integrating healthcare services with local partners, receiving facilities and healthcare systems.

“In 2014 we were able to exceed goals of insurance monetary savings, as we diverted 54% of ambulance transports to the emergency department among our 9-1-1 low-acuity patients who were evaluated by Community Care Units,” he continues. “These units are staffed with a captain/firefighter/paramedic and nurse practitioner, and Community Care Specialty Units that comprise of a captain/firefighter/paramedic and behavioral health specialist. These patients received an evaluation/assessment, treatment, referral to their primary care provider or other specialists, and/or alternative destination transport where definitive care was provided.”

While Smith notes Mesa is presently restricted by CMS grant guidelines from sharing additional numbers they’re currently collecting, the department remains excited about the successes it is experiencing and they believe they will exceed the goals the they’ve set for themselves.

Ichan School of Medicine at Mount Sinai

Project Title: “Bundled Payment for Mobile Acute Care Team Services”
Geographic Reach: New York
Estimated Funding Amount: $9,619,517

The Icahn School of Medicine at Mount Sinai project is testing Mobile Acute Care Team (MACT) Services, which utilize the expertise of multiple providers and services already in existence in most parts of the United States but seek to transform their roles to address acute care needs in an outpatient setting.

MACT is based on the hospital-at-home model, which has proven successful in a variety of settings. MACT treats patients requiring hospital admission for selected conditions at home. The core MACT team involves physicians, nurse practitioners, registered nurses, social work, community paramedics, care coaches, physical therapy, occupational therapy and speech therapy, and home health aides.

The core MACT team provides essential ancillary services such as community-based radiology, lab services (including point of care testing), nursing services, durable medical equipment, pharmacy and infusion services, telemedicine, and interdisciplinary post-acute care services for 30 days after admission. After 30 days, the team ensures a safe transition back to community providers, and provides referrals to appropriate services.

Kevin Munjal, MD, MPH, assistant professor of emergency medicine and assistant professor Population Health Science and Policy at Mount Sinai Hospital, notes while the MACT program utilizes the expertise of multiple providers, including physicians, nurses, social workers, paramedics and others, the partnership with paramedics providing urgent, telemedicine-enhanced, assessments and coordinated care with the MACT physician, are critical to the success of the program to avoid unnecessary hospitalizations and emergency room visits during the MACT episode.

“We are excited about the paramedicine aspect of the program and have begun training both our paramedics as well as our physicians, who are specialists in internal medicine and/or geriatrics, for this new care model,” Munjal says. “The program is envisioned to work as follows: A nurse and physician will be available 24 hours a day, 7 days a week to address any concerns the patient has over the phone. Experience with the hospital-at-home model elsewhere has shown that some proportion of these calls will not be resolved over the phone, and cannot safely wait for when a nurse practitioner, physician or nurse is available for an in home visit. The on-call physician will activate the paramedic response when he or she decides the patient requires urgent attention. Paramedics will visit the patient at home and operate under NYC Regional ALS Protocols but without automatically transporting to the hospital.

“With the help of General Devices’ eBridge, a video conferencing and telemedicine technology, paramedics will participate in real-time consultation with the MACT physician in order to make a collective and informed decision as to the appropriate course of action,” Munjal continues. “In this model, the paramedic will take medical direction from the MACT physician to administer medications and treatments in the paramedic’s existing scope of practice to help with patient symptoms and disease. The physician and patient will engage in shared decision making regarding transportation to the hospital. Patients will retain their rights to be transported to the hospital if they so desire or will document their preference to stay home in writing.”

Munjal says patients, caregivers and the general community have been very supportive of the overall MACT initiative. Patients seen in the emergency department are evaluated for inpatient admission through the usual pathways, and a patient will be considered for the MACT program only after the decision to admit has been made. He explains cases will be reviewed to identify patients who can be cared for safely at home. The following diagnoses will be considered:

• Community Acquired Pneumonia
• Urinary tract infection
• Congestive Heart Failure
• Diabetes
• Chronic Obstructive Lung Disease
• Cellulitis
• Venous thromboembolism
• Asthma