In just their first year, South Shore Health’s Mobile Integrated Health (MIH) program has served over 800 patients with comprehensive care at home. The program, which is the first hospital-run MIH program in Massachusetts, provides in-home care for patients with acute and chronic health conditions in order to reduce unnecessary ED visits, overcome barriers to accessing care and prevent hospital readmissions. As part of the MIH program, South Shore has implemented a SNF at Home initiative to support post-acute transitions and offer an alternative to brick-and-mortar skilled nursing facilities for patients.
MIH Paramedics: The bridge between hospital and home
South Shore’s MIH program is staffed by employed, specially trained paramedics with direct oversight by MIH clinicians. Patients can be referred to the MIH program by their PCP or from South Shore’s busy emergency room or acute care hospital. The paramedics serve as a bridge between the hospital and home, often enabling patients to receive an evaluation in their home as an alternative to an ER visit or decrease their length of stay in the hospital. By leveraging MIH Paramedics in the community, South Shore Health has been able to decrease unnecessary ED visits, reduce total cost of care, and improve overall patient satisfaction.
In the MIH SNF at Home program, paramedics partner with South Shore VNA providers to provide post-acute care in the home including skilled nursing services, physical therapy and occupational therapy to ensure patients are able to heal at home successfully. By leveraging MIH Paramedics in this capacity, South Shore also benefits from their unique ability to assess and triage patients in the home, and use a virtual consult to adjust a care plan or provide immediate intervention.
Creating a shared platform to improve communication & care coordination
In order for South Shore’s MIH team to operate as an extension of the health system, they needed to seamlessly coordinate patient care. In early 2021, South Shore implemented Current Health’s platform to provide additional insight into patients managed in the SNF at Home program to coordinate in-home clinical care and enable virtual intervention.
By leveraging Current Health to deliver healthcare at home, South Shore has been able to engage patients and caretakers in their care plan and connect patients with their providers virtually. Patient data is collected and can be acted upon remotely, triggering adjustments to medications, in-person visits by the paramedic, or telehealth visits with providers to optimize care in the home.
Expanding the SNF at Home program to higher acuity patients
With insight into patient’s continuous vital sign data through Current Health’s wearable device, South Shore felt confident managing higher-acuity patients at home. The continuous and passive nature of the monitoring has allowed the South Shore team to see trending patient vitals, allowing them to identify early signs of decompensation in a way that spot monitoring could not. South Shore’s MIH team has since added Current Health remote patient monitoring for their patients with acute heart failure in partnership with their local cardiology practices to provide comprehensive, real-time insight into patient status and enable them to adjust care plans accordingly.
Developing data-driven protocols for patient prioritization
In addition to real-time vital signs, Current Health’s clinical dashboard provides a single view of all patients in the SNF at Home program stratified by risk level. This enables the MIH team to better prioritize care outside of their regular visits to the patient’s home. The team has developed tailored alarms, using multiple vital sign parameters to make them highly-sensitive yet specific, that alerts the MIH nurses and paramedics when an in-home intervention was necessary.
Delivering virtual interventions to avoid hospital admission
Current Health’s clinical dashboard also enabled asynchronous and synchronous communication between the MIH team nurses, paramedics and providers, improving their ability to function as a unified clinical team. From within the home, MIH paramedics can conduct a video consultation with a provider who shares access to a patient’s vital signs. This way, the provider can virtually change a patient’s care plan or advise an intervention without the patient needing to be admitted to the hospital.
The patient and provider feedback surrounding MIH and the addition of Current Health remote patient monitoring has been overwhelmingly positive. Patients are thrilled with the level of care and attention to detail that they are able to receive in the comfort of their own home through the MIH program. For South Shore, the MIH program is an important tool that leverages the power of the health system to provide patients with the right care, at the right place, at the right time.