Leveraging MIH Against COVID-19

South Shore Health is an independent, not-for-profit regional health system located on the South Shore of Boston, Mass., with a 400-bed hospital, 100,000 annual visits to its emergency department, and a hospital-based emergency medical services program.

“EMS is more than transporting patients to the ED; it is a practice of medicine,” says Jason Tracy, MD, chair of emergency medicine at South Shore Health. “In a fully integrated EMS system, we can leverage the clinical acumen and procedural skills of paramedics to care for patients in both traditional and nontraditional settings. It is our responsibility as a health system to share our vision of EMS medicine and give our colleagues the tools, training, and equipment needed to be successful.”

While EMS plays a critical role in any hospital’s disaster preparedness, patient flow, and ED referral, the recently launched mobile integrated healthcare (MIH) program at South Shore Hospital has become an integral part of the health system’s response to the COVID-19 virus. Through MIH, patients with limited access to care, chronic health needs, or who are at high risk for readmission or excessive use of the ED are identified by their primary care physicians and ED providers. EMS professionals respond using evidence-based protocols combined with active medical control to provide immediate care in the home and connect patients with community resources or clinics. 

At the height of the pandemic, as the spread of the virus accelerated on the South Shore, patients became unwilling or unable to seek care in the hospital. Primary care clinics closed, elective surgeries were canceled, and nursing facilities became overrun and overburdened while experiencing staffing shortages. Immediately the South Shore MIH team of specially trained paramedics—mobile, flexible, and connected—pivoted to augment the sudden gaps in care. As a hospital-based service integrated with the health organization’s electronic health records system and known to providers and clinics, the MIH program quickly became an essential tool to allow the system to “flatten the curve.” 

Innovation at Home

A key focus of prepandemic health system operations was to improve system capacity and contain costs. The MIH program combines basic telehealth technology and a strong partnership with the local Visiting Nurse Association (VNA) and other home health services, proving that innovative, cost-containing practices don’t always require high-tech solutions. By including the capabilities of out-of-hospital programs, South Shore Health’s MIH program can improve access and quality while also embracing patient and family-centered care principles. Recent large meta-analyses have shown hospital-at-home-type programs reduce mortality, decrease readmissions, decrease cost, and increase satisfaction.^1,2

Patients who traditionally would require hospital admission for certain diseases, such as community- or healthcare-acquired pneumonia, congestive heart failure, chronic obstructive pulmonary disease, and cellulitis, can now receive hospital-level care in their homes as a full substitute for acute hospitalization. Paramedics provide physical assessment, lab acquisition, infusions, IV antibiotics, wound care, EKGs, and other critical services in the patient’s home while connected to hospital-based providers and specialists. By augmenting this acute care with the skills of traditional home health services (VNA, home physical and occupational therapy), patients can be followed and cared for in a dynamic fashion without ever needing the physical footprint of the hospital. 

MIH and COVID-19

As the rate of local COVID-19 cases quickly increased in Massachusetts, the MIH telehealth program adapted to keep patients safe at home while helping maintain patient flow and reduce hospital admissions. During the peak of the crisis, South Shore Hospital experienced a 50% increase in patient lengths of stay. Combined with PPE shortages and complicated infection-control procedures, this put the hospital at risk to become quickly overwhelmed. Through the MIH program, COVID-19-positive patients with moderate illness who would otherwise be admitted were able to be discharged. Patients received regular visits by paramedics, MIH telehealth monitoring, a pulse oximeter, and an oxygen condenser. Ultimately the program helped avoid 149 COVID-19 hospital admissions.

In addition, non-COVID-19 cases became priorities as patients refused to stay in the traditional healthcare setting. For example, one patient who had urgent open-heart surgery during the pandemic was adamantly against going to a rehab facility postdischarge due to the dangers of COVID-19. The South Shore Health team worked to successfully coordinate more than 30 days of postacute service in the patient’s home during her recovery. 

While some patients refused to enter nursing facilities, those already admitted to skilled nursing facilities, group homes, or psychiatric facilities became the hardest-hit population. Staff at these entities were pushed to the brink with illness, limited PPE, and little to no disaster planning or preparation. Again the integrated EMS system was used to allow these facilities to “stand and defend” through training, education, and infection control while preventing a massive influx of patients into the South Shore Hospital ED. MIH provided immediate acute care to patients in these facilities while being a reassuring and calming presence for exhausted staff. During the surge the MIH team tested 690 nonambulatory patients for COVID-19.

Summary 

In the seven months since its inception, the MIH team has conducted 2,200 appointments with patients in the community, including individuals with chronic illnesses, comorbid conditions, and those with little or no access to healthcare. To date the number of patients tested for COVID by South Shore EMS and its MIH team is well over 900—patients allowed to remain in their homes or facilities without having to come to the ED for testing. More than 200 patients were tested in their homes. Tests were conducted at 13 skilled nursing facilities, 10 assisted living facilities, and four psychiatric facilities. 

MIH paramedics also treated 150 COVID-positive patients with mild or moderate symptoms in their homes, avoiding admission and increasing capacity to care for our sickest patients at South Shore Hospital.

Agnostic to the payer, the team operates for patients and in service to the health system. It is funded by telehealth reimbursement and accountable care organization (ACO) or practice-based contracts, and follows a cost-avoidance strategy focused on preventing readmission and reducing bed-hour utilization. 

EMS medicine and operational design must evolve through innovation and close attention to patient and system needs. By combining MIH-type services with telehealth, alongside other services like visiting nurses, hospice, and 9-1-1, health systems can create capacity while embracing patient- and family-centered care. In turn, systems become better suited to enter risk-based contracts and manage capitated populations. 

Successful deployment of the MIH model of care, combined with advances in telehealth reimbursement, has set the stage for expansion to broader risk-based contracts and more efficient capitated population management while creating increased capacity for novel care within the footprint of the hospital. As South Shore Health begins to evaluate what worked and what did not during the first wave of the COVID-19 pandemic, leveraging a dynamic hospital-based EMS/MIH program has proven to be a vital element of the patient care model and will ensure preparedness for another surge in the future.   

References

1. Shepperd S, Doll H, Angus RM, et al. Avoiding hospital admission through provision of hospital care at home: a systematic review and meta-analysis of individual patient data. CMAJ, 2009 Jan 20; 180(2): 175–82.

2. Caplan GA, Sulaiman NS, Mangin DA, et al. A meta-analysis of “hospital in the home.” Med J Aust, 2012; 197(9): 512–9.

Sidebar: South Shore MIH: By the Numbers

• 2,200 community patient visits
• 1,000 COVID tests
• 150 symptomatic COVID patients treated in their homes

(Numbers current when issue went to press)

William W. Tollefsen, MD, MSc, MBA, FAEMS, is vice chair of emergency medicine and urgent care for South Shore Health.

Kelly Lannutti, DO, is MIH medical director and clinical innovation physician for population health at South Shore Health.

Eugene Duffy, NRP, is director of EMS and MIH for South Shore Health.