Evaluating Social Determinants of Health in a Mobile Integrated Healthcare-Community Paramedicine Program.

In 2018, the University of Maryland Medical Center and the Baltimore City Fire Department implemented a community paramedicine program to help medically or socially complex patients transition from hospital to home and avoid hospital utilization. This study describes how patients' social determinants of health (SDoH) needs were identified, and measures the association between needs and hospital utilization. SDoH needs were categorized into ten domains. Multinomial logistic regression was used to measure association between identified SDoH domains and predicted risk of readmission. Poisson regression was used to measure association between SDoH domains and actual 30-day hospital utilization. The most frequently identified SDoH needs were in the Coordination of Healthcare (37.7%), Durable Medical Equipment (18.8%), and Medication (16.3%) domains. Compared with low-risk patients, patients with an intermediate risk of readmission were more likely to have needs within the Coordination of Healthcare (RRR [95% CI] 1.12 [1.01, 1.24], p = 0.032) and Durable Medical Equipment (RRR = 1.13 [1.00, 1.27], p = 0.046) domains. Patients with the highest risk for readmission were more likely to have needs in the Utilities domain (RRR = 1.76 [0.97, 3.19], p = 0.063). Miscellaneous domain needs, such as requiring a social security card, were associated with increased 30-day hospital utilization (IRR = 1.23 [0.96, 1.57], p = 0.095). SDoH needs within the Coordination of Healthcare, Durable Medical Equipment, and Utilities domains were associated with higher predicted 30-day readmission, while identification documentation and social services needs were associated with actual readmission. These results suggest where to allocate resources to effectively diminish hospital utilization.

Evaluating the Impact of a Mobile Integrated Health‒Community Paramedicine Program on Health-Related Social Needs and Hospital Readmissions.

OBJECTIVE: Evaluate a mobile integrated health-community paramedicine program's effect on addressing health-related social needs and their association with hospital readmissions. METHODS: This observational study enrolled 1,003 patients from 5/4/2018-7/23/21. Descriptive statistics summarize social needs. A Poisson regression model examined the association of interventions for social needs with 30-day readmissions. RESULTS: Patients who had their medication-related needs fully addressed had a 65% lower rate of total 30-day readmission compared with patients who had no such needs fully addressed (IRR=0.35, 95% CI 0.18-0.68, P=.002). No variables reached statistical significance related to unplanned 30-day readmissions, aside from the HOSPITAL Score. CONCLUSIONS: Assisting patients with medication-related needs is associated with reductions in overall 30-day readmissions. Interventions within most domains were not associated with reductions in overall or unplanned 30-day readmissions. This program had greater success addressing needs with one-step interventions, suggesting additional time and resources may be necessary to address complex social needs.

Impact of a mobile integrated healthcare and community paramedicine program on improving medication adherence in patients with heart failure and chronic obstructive pulmonary disease after hospital discharge: A pilot study.

Background: The mobile integrated health-community paramedicine (MIH-CP) program affiliated with the University of Maryland Medical Center focuses on improving patient transitions from hospital to home by addressing both medical and social determinants of health. Until recently, only self-contained health systems could integrate inpatient and outpatient medication data. Without some means to track patients in transition, there is a significant risk of medication-related problems and errors. Objective: To evaluate the impact of the MIH-CP program on medication adherence among patients with congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD). Methods: This is a pilot observational study designed to compare adherence to drug regimens prescribed at hospital discharge (measured by the proportion of days covered [PDC]) between patients enrolled in the MIH-CP program and a propensity-matched control group. Propensity scores were calculated using 11 demographic, diagnostic, third-party payer, and patient care-associated variables. Discharge medication details were obtained from electronic medical records. PDC for each of the medications were calculated from pharmacy claims data. Results: Eighty-three patients were included in the study; forty-three patients were placed in the intervention group and 40 were propensity-matched controls. After adjusting for age, sex, and third-party payer, findings indicated that medication adherence was higher among patients enrolled in the MIH-CP program compared with control during the first 30 days post-discharge, specifically among patients diagnosed with CHF (8% difference in PDC, 95% confidence interval [CI], -0.12-0.28%) and COPD (14% difference, 95% CI, -0.15-0.43%), although neither result achieved statistical significance. The differences in medication adherence between patients who were enrolled and those who were not enrolled in the MIH-CP program diminished after 30 days post-discharge. Conclusion: This pilot study demonstrated a trend toward improved medication adherence among patients enrolled in the MIH-CP program. Future research involving a larger patient cohort will be required to confirm these preliminary findings.

Development of a Logic Model to Guide Implementation and Evaluation of a Mobile Integrated Health Transitional Care Program.

To provide medical and social services to underserved communities, many health care organizations across the United States have expanded the role of emergency medical services to include mobile integrated health and community paramedicine (MIH-CP). Although MIH-CP programs differ in structure and setting, many share the common goal of improving health through home-based, patient-centered care management models. Ideally, these innovative programs reduce use of health care services, including 911 (US emergency system) calls and emergency department visits. In 2018 a large, urban academic medical center partnered with the city's fire department to establish an MIH-CP program to support patients as they transition in their first 30 days at home after hospitalization. Prior to launch, a multidisciplinary team developed a logic model to guide development, implementation, and evaluation of this complex and innovative program. This paper describes the team's structured process for developing a logic model. It also describes key components of the initial logic model and the Transitional Health Support program structure, as well as subsequent revisions to both.

Innovative Use of Emergency Medicine Providers in an Urban Setting to Reduce Overutilization of 9-1-1.

BACKGROUND: Emergency Departments (ED) and Emergency Medical Services (EMS) are relied on to address nonemergent needs causing long ED wait times. Baltimore City EMS provided over 100,000 transports, many for low-acuity medical needs. OBJECTIVE: Minor Definitive Care Now (MDCN) is designed to address low-acuity complaints and decrease ED visits. MDCN provides low-acuity 9-1-1 callers the option of on-scene evaluation and treatment. For patients requiring additional resources, but not needing an ED, an alternate destination is considered. METHODS: Patients were screened low acuity by EMS personnel and voluntarily enrolled in MDCN. A questionnaire was given to patients after their visit to assess satisfaction. CRISP, a database for hospital visits in Maryland, was reviewed to assess if patients went to the ED after an MDCN visit. RESULTS: In 1 year of service, 168 calls were screened, with 144 patients consenting to treatment by the MDCN team. Of enrolled patients: 94 (65%) were treated on the scene, 37 (26%) were transported to an urgent care facility, 1 (0.6%) was transported to their primary care provider for a same-day appointment, and 12 (8.4%) were transported to the ED after further evaluation. Of the 94 patients treated on scene, 3 (3.2%) presented to a local ED in the surrounding area within 72 h. On review, there were no safety issues identified or deficits in the clinical care provided on scene. CONCLUSION: This innovative model of on-scene evaluation and treatment can potentially reduce transports, decrease ED wait times, and reduce costs, in an effective and efficient way.