• Innovation in Action

Jun 3, 2024

Mobile Integrated Healthcare Addresses Social Drivers of Health to Reduce Readmissions

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Within 10 months of operation, Citizens Memorial Hospital’s (CMH) Mobile Integrated Healthcare served 183 high-risk patients with 399 home visits for care planning and patient safety.  This program resulted from community planning to address social drivers of health negatively impacting residents’ ability to access healthcare across its rural service area.

While CMH’s readmission rates were already low compared to state and national averages, the addition of the mobile service reduced Medicare readmission rates by another 2.5%, according to Jenna Hicks, MBA, BSN, RN, Director of Quality & Population Health at CMH. This showed early potential to increase patient safety by integrating the new mobile healthcare delivery system within existing care models for serving those unable to access their provider within a traditional office setting, or to whom clinically warranted more time and education than could be provided in a singular office visit for best patient outcomes.

“We sought to redesign care delivery to improve population health, patient experience, and health equity for the patients we serve – and mobile integrated healthcare was just the right fit,” she said.

Next steps for further enhancing the program include provision of specialty service lines, in addition to primary care support, such as behavioral health crisis intervention, chronic care management, complex health-related social support and prenatal/postpartum care for high-risk mothers and babies.

While CMH was fortunate in being awarded a $1.8 million grant to fund vehicles, personnel and equipment, payers do not yet recognize direct reimbursement of mobile integrated healthcare services. However, CMH continues to promote the service’s value in costs saved and safety gained because of the overall improved health of the community.

“This grant has allowed us the opportunity to implement mobile integrated healthcare to evidence the impact this innovative care delivery model has on population health in hopes of gaining recognition by our payers for long-term program sustainability,” Hicks said.

Citizens Memorial Hospital is a 2023 Health Quality Innovator of the Year award winner in the Collaboration category. Click HERE to view their category. Also, click HERE to read about all the winners and runners up.

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