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Spreading Innovations in Health Care Delivery


This website, endorsed by Maryland’s Stakeholder Innovation Group, offers a glimpse at how many of Maryland’s health care providers and community organizations are working together to improve care delivery.

We urge you to use this site to share innovative programs and practices that improve the health of Maryland’s communities.



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Charles County Mobile Integrated Healthcare

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  • What are the objectives of the program?

    Improved health outcomes, Reduced readmissions, Increased use of preventive and primary care, Reduced avoidable utilization, Reduced spending

  • Please provide a brief description of the program:

    Charles County Mobile Integrated Health care or MIHealth is a unique partnership aimed at improving health care outcomes among medically vulnerable populations. This integral partnership between the Charles County Department of Health, University of Maryland Charles Regional Medical Center, and the Department of Emergency Services creates a health care network that extends beyond the hospital, and carries health and wellness into the community. Program participants receive home visits from an MIHealth team comprised of a registered nurse, paramedic, and community health worker. The MIHealth team can monitor patients at risk for re-admission due to chronic illness, and connect patients with community resources, which improves health outcomes, reduces repeated trips to the emergency room, and reduces calls to 9-1-1.

  • Is this program operated as part of HSCRC's Care Redesign Amendment?

    No

  • Which Center for Medicare and Medicaid Innovation (CMMI) category does (or would) the program fall under? Choose the best match.

    Initiatives to Speed the Adoption of Best Practices

  • What are the major components of the program?

    Care coordination/management, Patient assessment tools, Care transitions, Patient education/coaching/self-management, Multidisciplinary care teams, Patient care plans, Community health workers, Interventions to address social determinants of health

  • What types of organizations participate in the program?

    Physicians office (primary care), Hospital/health system, Behavioral health provider (e.g., mental health and/or substance abuse)

  • Which population(s) does the program target?

    Medicare/older adults, Medicaid, Dual eligibles (Medicare-Medicaid enrollees), Privately insured, Individuals with multiple chronic conditions, Frail/disabled

  • How many patients have participated in the program to date?

    48

  • In what Maryland jurisdictions do participating patients reside?

    Charles

  • Briefly describe the staffing resources required to operate the program:

    The Mobile Integrated Healthcare (MIH) Team includes a paramedic, a registered nurse, and a community health worker. Each staff member has a distinct role during home visits and care coordination.

  • Briefly describe the key initial steps to implementation:

    This project took several years of planning to come to fruition. Once funding was obtained, a planning team worked to develop all forms and data collection materials that would be used by the MIH team. Materials for education were developed. Materials from partner agencies were collected to ensure that the staff would be able to refer patients to appropriate services. Staff were hired and trained on the specifics of the program. A MOU was developed and signed by all 3 agencies working on this project. This was done to establish the roles and responsibilities of each agency to the implementation of the project.

  • Are incentive payments to health care providers part of the program?

    False

  • Does the innovation program qualify as a CMS Advanced Alternative Payment Model (APM)?

    Yes

  • What are/were the expected results in improved outcomes, population health, and cost savings?

    Expected improved outcomes for the target population include: 1. Decrease the percentage of ED visits and 911 system calls among participants by 25%. 2. Increase the number of participants who visit their primary care provider twice a year for routine care. 3. Increase health literacy by educating participants on prevention/management of their disease processes. 4. Make at least one referral per participant to a needed community, health, or social service. 5. Give people the tools to self manage their disease processes. The expected benefits to the hospital would be a decrease in their ED utilization among participants and a decrease in their 30 readmissions rate. Charles County EMS would also benefit in a reduction of 911 calls and EMS transports for non-emergent situations.

  • Have expected results for improving outcomes and population health been met?

    Yes, expected results were achieved

  • Please briefly explain your answer to Question 25, and describe any results for improved population health achieved to date:

    The program is tracking the number of ED visits and inpatient admissions by program participants, as a reduction in hospital use is a key outcome measure to document program impact. Charles County MIHealth has served 25 patients in its first 3 months of implementation. In the 3 months prior to MIHealth participation, these 25 patients had a total of 114 visits to the CRMC emergency department. After MIHealth, the number of ED visits among participants has dropped 74% to a total of 30 ED visits. The number of inpatient admissions dropped 84% from a total of 31 inpatient admissions 3 months prior to MIHealth to only 5 inpatient admissions in its first 3 months. The number of 30 day readmissions dropped from 10 to 1. Using the average costs for an inpatient admission and an emergency department visit, it is estimated that the MIHealth program has saved $191,800 in its first 3 months of implementation. , Yes, expected results were achieved

  • Please briefly explain your answer to Question 27, and describe any cost savings results achieved to date:

    The program is tracking the number of ED visits and inpatient admissions by program participants, as a reduction in hospital use is a key outcome measure to document program impact. Charles County MIHealth has served 25 patients in its first 3 months of implementation. In the 3 months prior to MIHealth participation, these 25 patients had a total of 114 visits to the CRMC emergency department. After MIHealth, the number of ED visits among participants has dropped 74% to a total of 30 ED visits. The number of inpatient admissions dropped 84% from a total of 31 inpatient admissions 3 months prior to MIHealth to only 5 inpatient admissions in its first 3 months. The number of 30 day readmissions dropped from 10 to 1. Using the average costs for an inpatient admission and an emergency department visit, it is estimated that the MIHealth program has saved $191,800 in its first 3 months of implementation.

  • Please provide URLs to any published evidence (e.g., peer-reviewed literature, white papers, etc.)

    http://www.mdruralhealth.org/wp-content/uploads/2018/01/MRHA-White-Paper-4-Executive-Summary-1.pdf