Leveraging Community Partnerships: Where Population Health, Global Budgeting and High-Quality Care Meet (98H)

This session outlines how Brattleboro Memorial Hospital (BMH) partnered with local EMS to develop a scalable mobile integrated health (MIH) program as an extension of its patient-centered medical homes to better address the needs of an aging patient population while simultaneously preparing to participate in CMS' AHEAD total cost of care pilot. The model began small, focusing on total joint replacement patients before expanding to include recently discharged patients and high-risk chronically ill patients with issues accessing care. Prior to discharge, patients are scheduled for an MIH visit. During these visits, paramedics assess the patient, review medications, draw labs and help facilitate follow-up appointments with primary care. MIH also serves as a temporary stopgap for patients referred for home health services. MIH paramedics administer IV antibiotics, provide wound care and offer many other services typically available via home health when there is a delay in getting the patient established with home health.

This shared care approach allows patients to be safely discharged sooner with follow-up MIH visits in place, often within 24 hours, which are subsequently followed with home health care. The results include increased access, decreased risk for readmission, and most importantly, meeting patients in their own homes where they are most comfortable. In a similar fashion, BMH primary care offices can identify and refer patients to both MIH and home health to catch patients early on and avoid unnecessary ED visits or admissions. With an aging population at higher risk for multiple chronic illnesses in a geographically isolated part of the state, this approach to caring for patients in their own homes allows for the proactive management of chronic illness and sets the stage for a more successful transition to global budgeting. This session underscores the value of collaborative, community-based care and provides learners with a blueprint for embracing innovative approaches to care and an understanding of how these types of models can lead to better patient outcomes and improved fiscal stewardship.