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New Mobile Health Program Works Toward Preventing Illness and Reducing Repeat Hospital Admissions

Hospital readmissions occur when a patient is admitted to a hospital after being discharged from an earlier hospitalization. Readmissions are a national healthcare focus, and in Mercer County, Capital Health is developing a new Mobile Integrated Health (MIH) program to help reduce the readmission rate for high risk patients.

Launched in September 2016 as a collaboration between Capital Health’s Emergency Medical Services (EMS) and Population Health departments, the program uses the strengths and experiences of EMS providers and Care Transition registered nurses in a whole new way to prevent illness and reduce repeat hospital admissions.

Patients are enrolled in the program two ways. Capital Health’s Care Transition registered nurses meet with identified patients during their inpatient stay and schedule the patient for a MIH home visit within a week of discharge from the hospital. “High risk patients include those with specific diagnoses such as heart failure, acute myocardial infarction, pneumonia, diabetes, and COPD, as well as patients who have extended lengths of stay in the hospital,” said Colleen Bowski, clinical manager of Care Transitions at Capital Health.

The program is also offered to patients who see providers at our Capital Health Medical Group offices or participating care providers in the Capital Health Accountable Care Organization and aren’t showing up for appointments or have high risk diagnoses. “Participation in the MIH program is optional,” said Angela Dito, director of Population Health at Capital Health, “but many patients are very receptive to this type of follow-up care.”

Once in the MIH program, patients receive in-home well visits by two-person teams selected from a pool of Capital Health paramedics, nurses, and emergency medical technicians. Currently operating on Mondays and Thursdays from 10 a.m. to 4 p.m., MIH teams review discharge instructions with each patient and his or her loved ones, check to make sure that the patient has access to his or her prescription medications, and look for safety hazards in the patient’s home. The teams also go over follow-up appointment details and help make transportation arrangements as needed to ensure continued care after hospital discharge.

In addition to the visiting teams, a population health registered nurse supervises each patient’s posthospital care and addresses any immediate concerns by collaborating with primary care providers, home health workers, and others when warranted.

For EMS providers in the program, the idea of preventing serious medical issues might seem like an unfamiliar concept, but the eyes and observational skills of our prehospital nurses, paramedics and EMTs are helping patients avoid being admitted to the hospital or a higher level of care.

In one instance, an MIH team on a home visit noted very subtle, early changes in their patient’s condition that turned out to be the beginning of sepsis (an extreme reaction to an infection, which can be deadly). Although a hospital visit was necessary, by detecting the changes early, the patient was treated before the condition took a more serious turn.

In another case, when a patient was having trouble keeping follow-up appointments, the MIH team discovered that an inoperative cellphone was the culprit. “Our MIH teams understand that small items can have big consequences. Keeping an eye out for things like faulty phones, loose furniture, rugs, and other fall hazards are all part of our mission,” says Greg Smith, manager of EMS Quality and Education at Capital Health.

“The feedback from patients has been very positive,” said Dan Schwester, EMS clinical coordinator at Capital Health, “and our team really enjoys getting to help the community in a way that is different from the traditional EMS.”