A health system uses mobile integrated health to improve outcomes and reduce readmission rates among patients with chronic conditions, such as heart failure and chronic obstructive pulmonary disease.

• The program involves sending a paramedic to where people, including homeless patients, live.

• The community-based program uses case managers.

• Among the positive outcomes was a seven-day readmission rate reduction from 40 people readmitting to 15 patients readmitting.

Healthcare providers continually seek new strategies to improve patient transitions. One Portland, OR, health system started a pilot program using mobile integrated health. The program involved a partnership between the health system and community paramedics, resulting in a drop in readmission rates from 6.75% to 5% within its first year.

“We started the pilot program to prevent readmissions for patients with chronic obstructive pulmonary disease [COPD] and heart failure,” says Tracy Neidetcher, MBA, MSN, NE-BC, manager of utilization management at Legacy Health System in Portland.

The program’s initial results were positive, so the hospital approved funding to continue the program.

“We noticed the patients we were referring to the program were not being admitted to the hospital,” Neidetcher says. “I shared data with our administrator, and we got the approval to go ahead and continue the pilot.”

The health system also opened the program to anyone who needed the service. Case managers could decide which patients would benefit.

“The nice thing about mobile health is you can serve a lot of homeless and underserved people,” she notes. “With mobile health, you can see patients who don’t even have a home.”

For instance, the program’s paramedics sometimes visit patients in their cars or at a tent city — even under a bridge.

The seven-day readmission rate dropped from 40 patients readmitting to the hospital to 15 patients, Neidetcher says.

The program is community-based and involves staff training. “We educated care managers, who are talking about the program and explaining it well to patients,” she says.

The pilot project’s own results showed what a big difference education made. After a great start, the program’s staff changed and the readmission rate bounced back to its baseline level because case managers were not enrolling people as aggressively as before.

“The numbers dropped, and people were not committing to the program,” Neidetcher says. “When paramedics reached out to them, they’d decline the service, so people weren’t doing as good a job of educating patients about it.”

After putting more effort into education, the outcomes again improved.

“It’s so critical to do a good job of educating staff. It takes time and does not happen overnight,” Neidetcher says.

Here’s how the mobile integrated health program works:

• Train staff. “The key is it takes time to get nurses to understand the program and buy into the program, to understand its value and how it takes extra time to see patients,” Neidetcher says.

Nurses need buy-in for the program, and their enthusiasm can help foster patient buy-in.

• Select patients. Legacy Health System uses a complexity score that is assigned to patients, and each patient has a readmission score.

Case managers review the complexity scores, readmission rates, risk scores, comorbidities, and support system to decide which patients would benefit most from the program.

“Maybe a patient is homeless and can’t receive home healthcare,” Neidetcher says. “The patient still needs support to go into their home, check on their medications, and follow up on their care.”

With a passion to help patients, case managers can succeed in helping even the most challenging cases.

“We have had patients who were readmitted 13 times, and we finally get them into mobile health, and now they don’t come back to the hospital,” Neidetcher says. “Those are the stories we need to tell case managers about.”

• Provide case management support. The case management workload was reduced to nearly half as many patients as previously.

“We’ve hired more people and moved some FTEs [full-time equivalents] in the system around,” she says. “Case management ratios were unruly, and we had to fix that to get staffing under control.”

The case managers meet with patients on inpatient floors. They talk with patients about the program, sharing information written at a fourth-grade reading level. Case managers also help facilitate transitions to paramedics in the program.

Once the patient enrolls in the program and leaves the hospital, paramedics take over.

• Paramedic follow-up. “Paramedics watch for the patient to be discharged, and then they commit to us they’ll make first contact within 24 to 48 hours,” Neidetcher says.

Usually, the paramedic’s first step is to call or text the patients. Often they have phones, but some can only receive text messages. Paramedics visit patients, using their regular vehicles instead of ambulances. Their work is separate from their emergency duties.

“If a patient is homeless, we’ll try to find out where they live,” she adds. “Paramedics know where the tent cities and the little cities under the bridge are. They’re very familiar with the homeless population.”

Paramedics even know various daytime habits of their homeless patients: “If they know a patient stands on this island to ask for money, they’ll drive past that island to see if they can find this person,” Neidetcher says.

• Making first visit. For patients with homes, the first visit might last two hours or longer. It includes an assessment of the patient’s activities of daily living, a physical assessment, and a full environmental survey.

They check all medications in the house to make sure patients are taking the right prescriptions and know how to take the medicine correctly. They check to see if shower bars are in place and if the toilet seat is raised and accessible. They pull up rugs that might be a hazard to patients. They check patients’ medical equipment and show patients how to handle and clean the machines, Neidetcher says.

The in-person visits typically are once a week. After the first visit, each visit might last 45 minutes to an hour. “They do vitals and use a health assessment checklist,” she says.

• Communicate with physicians. Paramedics will reach out to primary care physicians, as needed. This might happen to get a medication adjusted or to notify the doctor that the patient never picked up the new prescription because of a transportation problem.

“Paramedics will pick up their medication and bring it back to them,” Neidetcher says. “The important thing is to manage the patient’s health at home.”

• Concluding cases. “The program is for only 30 days. It’s to prevent the 30-day readmission,” she says. “Once we hit the 30-day post-discharge, the patient graduates from the program.”

The health system tracks the graduation rate and readmission rate, but does not continue to connect with the patient, she adds.