Queen Anne's County Mobile Integrated Community Health (MICH) Program

Description

Queen Anne's County, Maryland, does not have a hospital. To reduce emergency services, emergency department visits, and hospital readmissions, the Queen Anne's County Mobile Integrated Community Health (MICH) Program was created in 2014.

Program participants receive visits from these members of the MICH team:

• Department of Health community health nurse
• Department of Emergency Services paramedic
• University of Maryland Shore Regional Health at Easton pharmacist
• Peer support specialist if needed
• Licensed addictions counselor if needed

MICH received a three-year grant from CareFirst health insurance, which allowed the program to add a telehealth component in 2016. MICH also receives funding from other grants, partnering hospital systems, local funding, and in-kind services.

Services offered

The MICH program is available to adults who are considered high-risk for frequent use of emergency services, emergency department visits, and hospital readmissions or to any adult found to have unmet social or healthcare needs. Services to these participants include:

• Education about specific medical conditions
• Fall risk assessments
• Home safety checks
• Nutrition status (if someone has enough nutritious food)
• Social support evaluation
• Substance use risk analysis

When the MICH team schedules a home visit with a patient, they use the CDC's prediabetes risk test. If a patient scores a 5 or higher, the team asks the patient's permission to test their hemoglobin A1C during the home visit and send the results to their primary care provider. Then the team enrolls the patient in a National Diabetes Prevention Program lifestyle change program.

At the start of the program, participants receive a 90-minute home visit from a paramedic, who:

• Explains the MICH program
• Completes a physical health assessment
• Conducts a health and home safety assessment
• Talks with the patient about any home safety concerns

A community health nurse meets with the participant and completes the following:

• Inventory of any prescriptions
• Participant's medical history
• Health literacy assessment
• Participant's current social system

Nurses then use this information to refer participants to needed healthcare and community resources.

In a designated vehicle equipped for telehealth, patients can complete telehealth appointments with a University of Maryland Shore Regional Health at Easton pharmacist. The pharmacist completes a medical history with the patient: if the patient is taking their medications as prescribed, if the patient can afford their medications, if the patient can stop taking any prescriptions, and if different medications would work better. The pharmacist also makes sure patients are correctly using equipment like blood glucose testing and blood pressure monitors.

If any medication issues are identified, the pharmacist contacts the MICH team and the patient's primary care and specialist providers. The pharmacist then works with the paramedic and nurse to discuss barriers related to health literacy, medication costs, and transportation.

Patients receive a follow-up phone call at 3 months after the initial visit, an in-person visit at 6 months, a phone call at 9 months, and an in-person visit at 12 months. Depending on the patient's health at 12 months, the patient will either graduate from the program or receive additional follow-up calls and visits.

Results

Between July 2016 and March 2024, the program made 1,098 patient contacts and continued to see a reduction in emergency department and inpatient visits and costs.

Between July 2016 and June 2019, the MICH program enrolled 233 patients, with an average of 9.55 medications and 5.37 comorbidities per patient. Results show a reduction in use of emergency services, emergency department visits, and hospital readmissions at 30 days and 90 days after enrollment, saving a total of $3,393,908 in healthcare costs – an average savings of $14,566.12 per patient.

During telehealth visits, the pharmacist found that 21.8% of patients had a major issue with their medication and reported this issue to their primary care providers.

Program coordinators reported that patients show improved knowledge of health information and safety concerns. Post-visit surveys reported the following:

• 94% said they could better manage their health after the initial visit
• 96% said the telehealth visit with the pharmacist was helpful
• 97% of patients said they would recommend the MICH program

The MICH program won the Mid-Atlantic Telehealth Resource Center's 2020 Breaking Barriers through Telehealth Award in the "small, rural and/or safety net provider or organization" category.

This descriptive study discusses the most prevalent diagnoses and comorbidities among participants:

Scharf, B.M., Bissell, R.A., Trevitt, J.L., & Jenkins, J.L. (2019). Diagnosis Prevalence and Comorbidity in a Population of Mobile Integrated Community Health Care Patients. Prehospital and Disaster Medicine, 34(1), 46-55. Article Abstract

Challenges

Program coordinators noticed that, one year into the program, patients returned to their baseline usage of emergency services. Program coordinators decided they needed a better follow-up procedure, which led to the current procedure of follow-up phone calls and visits at 3-month intervals.

At the start of the COVID-19 pandemic, MICH visits were halted in March 2020. Visits resumed in June, but the number of visits per day/per week was modified. The decision to decrease the number of visits was made due to the amount of time that putting on and taking off full personal protective equipment (PPE) and decontaminating equipment and the MICH vehicle added to each visit. Before the pandemic, home visits typically took 75-90 minutes to complete, but home visits now took up to three hours. From August 2020 to January 2021, the MICH team was able to scale up operations to 2 visits/day, 3 days/week, with each patient screened over the phone for COVID-19 risk approximately 24 hours prior to their visit.

Home visits were halted again in January 2021 and the MICH team's role shifted, staffing the Queen Anne's County COVID vaccination clinic once a week and traveling to assisted living and senior housing facilities within the county twice a week to provide vaccinations to residents and staff. The team hosted two clinics in 2022 to test for diabetes, and regular home visits resumed March 2022.

Replication

Include your stakeholders in the planning process as early as possible and keep them involved in program development. This gives stakeholders ownership and buy-in into the program and creates a collaborative process that will aid your program's development. Attempt to make your stakeholders and partnerships as diverse as possible. Diversity in collaboration creates strong programs.

Your program should be designed to be flexible enough to make acute changes to adapt to any obstacles or issues that may arise. For example, to address patient utilization returning to baseline at a year from enrollment, the program adapted and changed the follow-up procedure to be more robust.

Prioritize data collection. Collect as much data as you can, as early as you can. Data will be used to leverage funding and inform stakeholders on program success. Plan to collect case studies and success stories along the way.

Contact Information

Jared Smith, Program Manager
Queen Anne's County Department of Health
240.580.6631
jaredb.smith@maryland.gov