Somers, S., Fitzpatrick, S., Hicks, C. & Gingold, D. (Fall 2022). Enhanced telemedicine in a mobile integrated health program to improve healthcare access during Covid-19 pandemic. Online Journal of Nursing Informatics (OJNI), 26 (2), https://www.himss.org/resources/online-journal-nursing-informatics
Background: When the COVID-19 pandemic struck, primary care and specialist visits declined. During the pandemic, Baltimore City Mobile Integrated Health (MIH) continued with targeted home visits among complex patients to help reduce hospital readmission rates. Many provider offices and specialists were closed for in-person clinic visits, creating disruption in continual care of chronic disease. To fill in gaps in care, MIH sought to facilitate these visits via telemedicine for their complex patient population.
Methods: A retrospective chart review of MIH-enrolled patients was performed from March 2020 to August 2020. State health information exchange systems were also reviewed for hospital contact. To evaluate if the telemedicine visit was effective in reducing the readmission rate, the study compared the risk-adjusted readmission rate and chi square analysis of patients who received a telemedicine visit with their primary care/specialist as a part of their MIH visit versus MIH patients who did not.
Results: From March 2020-August 2020, telemedicine was utilized 26 times for 14 patients to connect with their providers. The risk-adjusted readmission rate for MIH patients that received telemedicine primary care/specialist visits were 7.7%; the rate for MIH patients who did not was 16%. Chi square analysis did not reveal statistical significance among the two groups.
Conclusion: Flexible and innovative use of telemedicine technology improves team communication and can also be used to facilitate existing care relationships between underserved populations and their care providers.
The University of Maryland Medical Center (UMMC) partnered with the Baltimore City Fire Department (BCFD) to form Mobile Integrated Health (MIH) in 2018. This partnership aims to support medically complex patients’ transition to home after hospital admissions. This innovative, community-based program supports the health of individuals through a comprehensive, multidisciplinary care model that provides patient care outside the hospital setting. The program is designed to reduce health disparities, decrease emergency department visits, and prevent hospital readmissions.
One of the main objectives for this MIH program is to have patients connect with their primary care providers (PCPs) shortly after discharge so that the PCPs can continue to manage their chronic health conditions and medications and prevent readmission to the hospital. Prior to March 2020, none of the patients enrolled in UMMC-BCFD MIH utilized telemedicine for their medical visits (Mobile Integrated Health Community Paramedicine Program, 2020). During the COVID-19 pandemic, the Centers for Disease Control and Prevention (CDC) issued guidance advising patients and health care providers to practice social distancing and encouraged the use of telehealth (Koonin et al., 2020). A study conducted by the Department of Veteran Affairs (VA) found that there was a 56% decrease in in-person outpatient visits during the COVID-19 pandemic (Baum, et al., 2021). However, the UMMC-BCFD MIH program remained in operation with no change in staffing or practice. With the need to connect patients with their PCPs, the UMMC-BCFD MIH program needed to pivot their normal operations to continue to meet the needs of the patients.
A retrospective chart review was completed to evaluate the enrollment rate of visits facilitating PCP and/or specialist encounters and if in-person visits impacted hospital re-admission rates among this population. Prior to the pandemic, patients that were enrolled in the MIH program regularly saw their PCPs in-person from 40-80% of the time during their enrollment. However, when COVID restrictions began, those in-person visits decreased to about 20% of the enrolled patients seeing their PCPs. The MIH program was able to change its normal operation to connect patients to primary care providers and specialists via telemedicine to meet the needs of medically complex patients during a pandemic.
In the UMMC-BCFD MIH program, community paramedics with advanced training are able to function outside traditional emergency response and transport roles; the paramedics also assist in maintaining individuals’ health at their homes by providing convenient access to care. Nurses and paramedics visit the patient in their homes after discharge and connect with medical oversight and additional resources through a secure telemedicine platform. The MIH program had been utilizing telemedicine prior to the COVID pandemic for staff communication only and had not been utilizing this modality previously to connect with the patient’s PCP or specialist. This program was non-billable, which allowed the utilization of telemedicine free from billable restrictions.
Due to the large impact of readmissions, this population of patients with chronic health conditions is vastly studied. In a large retrospective comparison, researchers compared data from several research articles across Westernized countries to evaluate risk factors for readmission within 30 days of discharge. These researchers found that elderly, male gender, non-white persons’ prior readmissions and comorbidities increased their risk for readmission (Pedersen, et al., 2017). Many of these characteristics relate to the patient population served by MIH (Table 1).
Telemedicine is among the multitude of best practice modalities studied to reduce hospital readmission rates. MIH used telemedicine as one of its platforms to aid in communication and to help target high-risk patients within Baltimore City. Prior to the pandemic, telemedicine was not highly utilized for regular medical visits due to restrictions on its use and reduced billing reimbursement for the provider (Centers for Medicare & Medicaid Services, 2020). To increase telemedicine utilization, the expansion of telehealth waiver 1135 for the COVID public health emergency was created. Coverage for telemedicine now included its use at any health care facility, no longer requiring rural environments only, as well as at patients’ homes (Centers for Medicare & Medicaid Services, 2020). Reimbursement expanded to physicians, nurse practitioners, clinical psychologists, and social workers.
Another dramatic change was the amount of reimbursement. Previously, telemedicine/telehealth visits were reimbursed at a lower rate as mentioned above, but with the waiver, telehealth/ telemedicine appointments were reimbursed the same as an in-clinic appointment (Centers for Medicare & Medicaid Services, 2020). This waiver also approved audio-only visits to be counted as telehealth/telemedicine. Between the summer and fall of 2020, more than one in four Medicare beneficiaries had a telehealth visit (Koma et al., 2021). The CDC reviewed trends in telehealth encounters, with the first quarter of 2020 seeing a 50% increase in telehealth visits compared to first quarter of 2019 (Koonin et al., 2020).
A MIH nurse practitioner performed a retrospective chart review of active patients in the UMMC-BCFD MIH program between March 2020 and August 2020. Consent to access patients’ medical records was obtained upon enrollment in the program. Utilizing UMMC hospital electronic medical records (EMR), data were collected for each MIH patient that was enrolled and included demographics, co-morbidities, and involvement of a PCP or specialist via telemedicine during their MIH visit. All patients that were enrolled in the MIH program were then evaluated for readmission via chart review using CRISP, the state designated health information exchange for Maryland. In addition, patient satisfaction was assessed via a self-reported survey using a 10-point scale, with 1 being low and 10 being excellent.
Comparisons were made between patients who utilized a PCP or specialist via telemedicine during the MIH visit versus patients not using a PCP or specialist via telemedicine during the MIH visit. Statistical analysis was completed using Health Services Cost Review Commission’s (HSCRC) risk-adjusted methodology to review readmission rates of enrolled MIH patients utilizing PCP/specialist vs. enrolled MIH patients who did not utilize PCP/specialist telemedicine visits. Chi square analysis was also completed to evaluate for statistical significance between the two groups.
From March 2020 to August 2020, 229 patients were enrolled in the MIH program. Demographics for UMMC-BCFD MIH patients who utilized telemedicine with PCP and/or specialist are seen in Table 1. Telehealth was utilized 26 times for 14 patients to connect with their PCP or specialist. The UMMC heart failure clinic was the most utilized specialty, with 21 visits. The PCP joined for 5 visits. These visits ranged from one to four episodes of a PCP/specialist joining the MIH visit. During the 30-day enrollment period, of the 14 MIH patients who received PCP/specialist telemedicine encounter, threepatients were readmitted.
The satisfaction of patients enrolled in this program was also evaluated. All MIH patients who participated in a telemedicine visit with their PCP/specialists rated their satisfaction 10 out of 10on a numeric scale via survey. MIH patients who did not participate in a PCP/specialist visit rated their satisfaction with the MIH program at 9.8 on scale of 1-10. By pivoting to include a PCP or specialist in a telehealth visit, the MIH team was able to increase the capacity for patients “seen” by their providers. As illustrated in Figure 1, in February 2020 approximately 80% of MIH patients saw their PCPs via an in-person outpatient visit. However, in-person PCP/specialist visits of MIH patients drastically decreased from February to March 2020. With the addition of telemedicine during MIH visits, approximately 70% of patients were now able to see their PCP/specialists in April and May. With the addition of telemedicine to MIH visits, the PCP/specialist follow-up rate was similar to pre-pandemic levels.
Readmission rates of all patients enrolled in the MIH program were also evaluated. Based on HSCRC methodology, risk-adjusted readmission rates for MIH patients that received telehealth visits with specialist/PCP visits were less than the MIH patients who did not (Table 2). Chi square data analysis was also completed, comparing the readmission rates of MIH patients that utilized telemedicine with their PCP/specialists to MIH patients that did not. Chi square data analysis showed p value of 0.08, which did not show a statistical significance of intervention.
There are several limitations to this study. Due to the need to pivot in real time to meet the needs of the patients during a pandemic, there was an impromptu addition of PCPs and specialists to already-occurring home visits from MIH community paramedics; this addition affected data collection. Selection bias could also have occurred for patients who received telemedicine. Many of enrolled patients had heart failure as a co-morbidity. The UMMC heart failure clinic was well connected with the program, so heart failure specialists had an easier time joining MIH visits via telemedicine than other specialists and accounted for the large number of specialist telemedicine visits. There was also a small intervention sample size of 14 patients who received telemedicine with a PCP/specialist during an MIH visit. More time and a more schematic process to add these patients’ specialists and increase provider involvement may have captured more willing participants.
The UMMC-BCFD MIH program only enrolls patients living in certain zip codes in Baltimore; this locational focus affects sample size and generalizability. For satisfaction surveys, only 5 out of 14 patients completed their survey. In addition, CRISP only reviews neighboring hospitals, so patients visiting hospitals not participating in CRISP would not be captured. These factors affected data collection and analysis and impacted the ability to determine if other unmeasured confounding difference are responsible for the results.
The previous operation of telemedicine for medical oversight for an MIH patient included an electronic device brought by the team into the patient’s house to provide video and audio for medical oversight only. This operation was pivoted to include the patient’s PCP or specialist in already-occurring MIH home visits to meet real-time demands of patients as in-person clinic visits of MIH patients drastically dropped in February 2020. With addition of MIH telemedicine capabilities, 14 patients were able to visit their PCPs or specialists in the comfort of their own homes.
During the COVID-19 pandemic, primary care and specialist offices reported a decrease in patient visits. UMMC-BCFD MIH patients had a sharp decrease in clinic appointment attendance from February to March 2020. With the addition of telemedicine to normally occurring MIH visits, attendance rates in April and May 2020 reflected pre-pandemic levels. This follow-up rate would have been less without the telemedicine addition to MIH visits. Attendance with a PCP/specialist is crucial when dealing with medically complex patients who are recently discharged from the hospital, as prompt PCP follow up after hospital discharge is associated with reduced readmissions (Lam, et al., 2018).
This meeting was desirable for both the patient and the managing provider. The PCP or specialist was still able to bill for a telemedicine visit when joining MIH visits, as MIH staff members are unable to bill for the visits. The PCP or specialist was able to obtain a full set of vital signs from on-scene community paramedics and engage in conversations and examinations of patients with audio and video capabilities. The patients’ satisfaction was measured via self-reported survey and all patients who returned the survey were extremely satisfied with the addition of PCPs/specialists to MIH in-home visits.
When reviewing readmission data, the group of MIH patients that were able to see their PCPs/specialists in conjunction with their normal MIH in-home visits had a decreased readmission rate compared to MIH patients that did not see their PCPs/specialists via telemedicine with MIH-in home visits. The risk-adjusted readmission rate for telemedicine patients was 7.7%, which was lower than the 16% rate of MIH patients who did not participate in advanced telemedicine. Chi square data analysis did not show a statistical difference between the two groups. While this analysis may not show causation as readmissions are multifactorial, telemedicine may be one aspect to aid in decreasing readmissions.
Implications for Nursing Practice
With the current medical landscape during the pandemic, interventions that improve patient access to healthcare should be promoted. With the expansion of telehealth waiver 1135 for COVID public health emergency lifting many of the previous telemedicine restrictions, more patients have been able to attend PCP appointments from the safety and comfort of their homes. All healthcare providers should encourage the waiver to remain in effect and encourage patients to utilize telemedicine.
Nursing and health informatics will also change to adapt and meet the needs of the changing medical landscape. Nursing informatics have the potential to expand via improved tele-communication services and/or improvement of patient access to these services. Staying current with technology upgrades and promoting patient utilization of these services will help overcome barriers to access to care such as patient mobility, future pandemics, and/or inclement weather and will help a fragile, medically complex patient population to connect with their PCPs or specialists.
During the COVID pandemic, MIH was able to help facilitate provider and patient connection to coordinate the needs of patients. In addition, this program was able to slightly decrease hospital readmission rates for the enrolled patients. To meet the needs of these patients during the changing landscape of a pandemic, an MIH program needs to be innovative. This can be achieved through advocating for the use of telemedicine with PCPs or specialists, resulting in high patient satisfaction and a reduced rate of readmission. Last, the continued expansion of health informatics will help to determine the future of this program and similar programs aimed at utilizing technology to overcome barriers to patient-provider encounters.
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Sarah is a senior nurse practitioner in the Mobile Integrated Health (MIH) program in the city of Baltimore. She has led multiple initiatives in this program to enhance the education of community paramedics toward improving the care of medically complex patients. Sarah Somers graduated with her degree in family nurse practitioner from George Mason University.
Suzanna Fitzpatrick, DNP, ACNP-BC, FNP-BC
Suzanne is a nurse practitioner at the University of Maryland Medical Center in Baltimore, where she has worked since 2008. She is a senior nurse practitioner with expertise in surgical patients, transplant, oncology and emergency medicine. She has a passion for mentoring novice nurse practitioners in their transition into practice and in their professional development. In addition, she is an adjunct professor teaching system and complex leadership theories and practical strategies to doctoral nursing students at the University of Maryland, Baltimore. She is co-founder of the Healthcare Leadership Community of the International Leadership Association.
Courtney Hicks DNP, FNP-C
Courtney is a nurse practitioner in the Emergency Department of Baltimore City. She is passionate about educating nurse practitioner students and precepting new colleagues, as well as collaborating with others on improvements of emergency department throughput.
Daniel B. Gingold, MD, MPH, FACEP, FAAEM
Daniel is an assistant professor in emergency medicine at the University of Maryland School of Medicine in Baltimore. He works clinically at the UMMC and serves as the medical director for the Baltimore City/UMMC Mobile Integrated Health (MIH) program. He heads the program’s monitoring and evaluation efforts, refines operational protocols, and serves as liaison to medical students and residents seeking research experiences regarding the MIH program and population health.