Treating Chronic Disease Patients at Home With a Mobile Integrated Health Team

In today’s health care arena, hospitals struggle to meet the established Medicare reimbursement requirements for providing safe and comprehensive care to admitted patients. This has resulted in patients being discharged even faster than in previous times in order to conform to the Centers for Medicare & Medicaid Services’ Hospital Readmission Reduction Program (HRRP) which was implemented in 2012. This reimbursement schedule for allowable hospital days is based on diagnosis codes which penalize hospitals up to 3% of operational diagnosis-related groups (DRGs). This loss in revenue occurs when hospitals are penalized financially if the patient is readmitted for any cause within 30 days following discharge from an inpatient stay.

One method of readmission reduction that has gained the attention of hospital leaders is called mobile integrated health care (MIH). In this program, local emergency medical services (EMS) staffed with paramedics, a resource already well established in almost every community and available 24/7, are trained to emergently assess a patient’s condition. Some hospital systems and EMS companies have empowered this resource to expand their capabilities to treat chronic patients in their home to reduce emergency department (ED) congestion and readmissions. This has helped to relieve access issues by getting patients seen when they need a provider; it has reduced the overuse of ED resources, and generated better patient outcomes. Published research has discussed the benefits of home care conducted by paramedics leading to improved patient care through monitoring, education, and faster access to health care.
By adding nurses and clinic staff into the workflow, we were able to streamline the criteria review for admitted chronic disease patients which reduced the paramedics’ workload and allowed them greater productivity in the field. This retrospective study reviewed a sample of 320 congestive heart failure (CHF) patients who were seen for an exacerbation of their chronic disease symptoms in the ED and either released home or admitted for an inpatient stay. Their ED and physician office visits were tracked for 90 days both prior and after an admission for those who entered the home visit program and those who refused the program. The same parameters were utilized to compare the MIH program before and after the added clinic staff assistance.