You Be the CP: Case Studies of Complex MIH Patients

The patients seen by mobile integrated healthcare and community paramedic programs are among the most complex out there. While CP leaders have now devised a standardized framework for evaluating their needs, much remains subjective when individual medics sit down to rate individual patients.

Wednesday’s EMS World Expo session on MIH-CP patient management challenges provided an opportunity for providers from different departments to collaborate on a pair of case studies and work jointly through that evaluation framework, known by the mnemonic CP’S MERITS. The idea was to benefit from each other’s experiences and ideas.

CP’S MERITS was developed by Dan Swayze, PhD, COO of the Center for Emergency Medicine of Western Pennsylvania, and Anne Jensen, EMT-P, special projects coordinator for San Diego Fire-Rescue. Jensen led Wednesday’s session with Faith Applewhite, NRP, from the Santa Fe (N.M.) Fire Department. They were joined by community paramedic Shawn Percival, who works with Jensen in San Diego’s Resource Access Program (RAP), and Santa Fe mobile health paramedic Ramos Tsosie, a colleague of Applewhite’s in Santa Fe Fire’s Mobile Integrated Health Office (MIHO).

Both departments use CP’S MERITS, but to galvanize the exchange of ideas, they crossed services to work through the case studies, with Percival and Applewhite leading the first and Tsosie and Jensen the second.

CP’S MERITS

The mnemonic, described in a 2019 EMS World article by its creators, helps providers understand the nature and severity of the patient’s condition, establish a baseline to measure change over time, and provide a road map for care planning. It stands for:

• Clinical—The medical issues familiar to EMS providers: status, history, medications, utilization, and understanding.
• Psychological—Mental health comorbidities: mental health history, medications, substance use disorders, use of care services. 
• Social—The support of friends, family, and other systems.
• Meals—Hunger, nutrition, eating disorders, and food hygiene. 
• Environment—Environmental factors that influence health, not only extreme temperatures but housing conditions and broader geographical and community infrastructure hazards. 
• Records—Patient records that help or deter access to services: identification, criminal records, etc. 
• Income—Cash and noncash. Navigating the application processes for subsidy programs or disability status is complex and can require help.
• Transportation—Patients who lack reliable transportation or have challenges navigating public transit often call 9-1-1 for their transportation needs.
• Skills—The patient’s skills—i.e., literacy and competence—in each domain are vital to their ability to resolve problems on their own.

Each of these dimensions is measured as threatening (in need of immediate assistance), unsustainable (working but not for long), sustainable (not ideal but could work long-term, such as a person adapted to homelessness), or ideal. Once rated they can be prioritized for action, with threatening and unsustainable situations taking natural priority.

Patient A: Dementia and Tylenol

Percival described a mid-60s female living in a city neighboring San Diego who, during their 18-month collaboration, called 9-1-1 400–500 times in her own town and another 80 in San Diego.

He judged her clinical and psychological situations threatening: She had dementia with severe behavioral and cognitive impairment, and often sought Tylenol for arthritis pain in her wrist. She’d overdosed on it previously and didn’t understand the danger of taking too much. She was triggered by family, and while her dementia made any help difficult, her problems seemed mostly behavioral, Percival said.  

Meals, records, and income weren’t a problem (ideal), but the other four domains were all unsustainable: Family (social) was tiring of her repeated 9-1-1 calls and false claims of abuse. She was housed (environment) but not always supervised and thus could go out for Tylenol. (She’d also leave the gas stove on, which, while caught each time by her husband, could raise the situation to threatening, Percival noted.) Her calling 9-1-1 for transportation couldn’t be sustained, and taxi companies had begun refusing her service over repeated nonpayment. And while she could basically self-care (skills), the stove issue and persistent nonunderstanding of Tylenol overdose dangers left that unsustainable too.

Two threatenings, four unsustainables—a tough patient for sure. The proposed big-picture solution was conservatorship, and her daughter was willing to assume it. But a barrier popped up: Despite the dementia, she was deemed to have the capacity to consent. The county’s patient advocate suggested a special conservatorship with dementia powers, so now Percival’s team is working with the hospital social worker to navigate that application process.

A lesson here: Sometimes you need multiple plans. “You never know where it’s going to lead you,” said Percival. “You think you’ve reached the end goal, then the goal posts have been moved on you.” 

This patient’s unsustainable dimensions also intertwine with the conservatorship, but it is rarely used, hard to get, and COVID has slowed court processes. The team is currently awaiting a decision.

Patient B: Chronic Pain and Opiate Use

Tsosie said his department has found the CP’S MERITS framework useful but added an extra legal domain after missing some patient arrests.

The patient he described was a 41-year-old male, mostly homeless, who lived part-time with extended family in the pueblos outside Santa Fe but frequently traveled to town with his mother. In the 18 months they’d worked with him, he’d overdosed on opiates 16 times they knew of and maybe more. He’d also been hit by motor vehicles several times and had TBI and a leg injury that caused chronic pain—a big driver of his substance use.

Obviously the ODs made his clinical situation threatening. Psych was too: The TBI caused problems with impulse control, Tsosie said, and it was hard to get this patient to appointments. Drugs and alcohol were easily available.

Meals and transportation were judged sustainable, but the income domain rose to threatening because the patient was focused on getting disability to the detriment of any other efforts at self-help.

All other dimensions were unsustainable: Family (social) was loyal, but he couldn’t use at the pueblo so often didn’t stay. In town (environment) he often slept on the streets. He wanted disability but was unable to collect the necessary paperwork (records). He had good social skills, but lack of impulse control often led to aggression. And while he had various court issues (legal), complying with such requirements wasn’t usually a priority.

Three threatenings, five unsustainables—another tough one. But while this patient clearly needs help, his repeat overdoses forced the team back to a much more basic posture: just trying to keep him alive. They gave naloxone to him and his family and took him repeatedly to a harm-reduction clinic in an effort to habitualize his use of it. His income domain was also difficult to address: He’d applied for disability and been denied twice, so they connected him with a representative to help, but he continues to miss appointments.

Beyond that the team has worked to stay in close touch with the patient, keep a feel for his baseline, and offer support and positive social interactions. Tsosie described those interactions as oxygen to those in such challenging circumstances—without them, he said, “it’s hard for you to think and feel and navigate the world.”

Conclusion

Efforts to help these patients are ongoing. You may face some equally as difficult. There aren’t right or wrong answers with CP’S MERITS, and the point isn’t that you should agree with all the ratings here. It can be subjective and vary with community resources. The lesson is there’s value in sharing multiple perspectives and working through such assessments with additional sets of eyes—that’s something community medics often need.

John Erich is the senior editor of EMS World.