February 14, 2016

Integrated Mobile Healthcare

What do Arkansas, Idaho, Maine, Minnesota, Tennessee, Washington, Missouri, Nevada, and Ohio have in common? No, they're not the states that hold primary elections on Super Tuesday (though several will). They're the states that have approved some kind of Mobile Integrated Health Care System, and as of December 31, Massachusetts joined the pack. What this means is that ambulances can be dispatched to patients’ homes to do something quite different from what they usually do, which is to bring patients to the hospital. Their mission is to institute treatment that will keep patients out of the hospital. And that’s exactly what frail older people need.

A few years ago, several of my colleagues and I were brainstorming about how our medical practice could improve care for our frailest, older patients. We lamented that most patients had to choose between staying at home with hospice care or going into the emergency room when they developed any kind of acute illness. Many of them felt hospice care was too little (it only addressed their symptoms but made no attempt to fix the underlying problem, even if it was something simple such as a urinary tract infection) and emergency room care was too much (when an 85-year-old with multiple medical problems and a fever shows up in the emergency department, a slew of tests and admission to the hospital are virtually guaranteed).

The available in-between solutions weren’t good enough: a visiting nurse was rarely equipped to diagnose and treat, and urgent care centers were often inaccessible or unavailable. One nurse practitioner came up with a great idea: she proposed that we buy a van, outfit it with supplies ranging from a portable EKG machine to the apparatus for starting an iv and giving intravenous fluids, and organize a mobile acute-care-at-home service. But the organization felt the investment was too great and the benefits too uncertain. Mobile Integrated Health Care will do just what we envisaged, but with a twist: it will take advantage of paramedics’ training, of the fact that they routinely carry just the right kind of the equipment in their ambulances, and that many ambulance services have a fair amount of down time.

The Massachusetts legislature passed a law authorizing the Department of Public Health to oversee such a service in November, 2015, effective December 31. An 18-member “Mobile Integrated Health Advisory Council” has already been appointed by the Commissioner of Public Health to carry out the mandate to create such a service. Ambulance companies, fire departments, emergency medicine physicians, home care companies, and others are all coming together to try to make this work.

Two critical pieces that ought to get a lot of attention as the Council proceeds with its work are interactions with primary care physicians and advance care planning. Traditionally, it’s been emergency room doctors sitting in hospital emergency departments who give direction to paramedics in the field; for this new model to work well, primary care physicians should be the ones calling the shots. They will be providing the follow-up care, not the emergency room staff. And this system could dovetail beautifully with the Massachusetts Orders for Life-Sustaining Treatment (MOLST), a system already in place that allows patients to spell out the approach to care they want if they develop an acute illness. A completed MOLST form should be available to the paramedics to help them understand just what treatments the patient decided, well before the stress of the acute situation, were appropriate to consider.

The idea of Mobile Integrated Health Care is terrific, but we need to look carefully at its outcomes. So far, existing systems have been described but not studied. We have a chance to design a promising program and then to actually figure out whether it’s working. What a novel idea indeed.

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