2021 Seed Grant Award Problem Statements 

Health and Wellbeing

Problem #3: Antiquated reimbursement models are promoting over use of the hospital and limit access to Primary and Specialty care. 

Country/Region of execution:  Bronx, NY, USA
Collaborating Organization: Empress Mobile Integrated Health
Empress Mobile Integrated Health has been working with SBH and the Bronx population since 2018. Empress collaborated to facilitate transitional care for patients considered “high utilizers” who are often unnecessarily in the hospital with conditions that can be managed at home. Empress was hands on with patients for 30 days’ post discharge facilitating home treatment, medication reconciliation, appointment scheduling and referrals based on their need’s assessment. Empress saw an over 50% reduction in 30-day readmissions among high ED utilizers and over 75% reduction among the inpatient population. Uniquely positioned to help EMS provides highly reliable patient assessment and treatment in response to emergency, urgent or unscheduled episodes of illness or injury. Services provided as part of MIH-CP can effectively navigate patients needing urgent or unscheduled care through the healthcare system to ensure they receive the right care, in the right place, at the right time.
Problem Statement Description:  Medically fragile and chronically ill patients with multiple chronic conditions have frequent health status changes and related concerns. Many of these high-risk individuals face daily challenges in understanding, accessing, and navigating the healthcare system; ultimately leading to primary ED use, frequent readmissions and may lack post-acute services. The development of innovative, collaborative partnerships could provide early intervention and additional layers of support to assist these individuals in improving overall quality of care delivered in the right place at the right time. Our experience with this population identified that access to “follow up” or same day care was inadequate. Patient volume in the Bronx causes unique access issues in which recently discharged patients can’t get into their follow up appointments for weeks or even up to a month and half post discharge. Same day access for immediate low acuity issues is near impossible which leads to patients seeking the instant satisfaction of the ED. Our culture has promoted the use of the 911 system, therefore it has led to the misuse of the EMS system and overuse of the hospital. This model has not translated with modern day solutions that may be better suited in a prehospital setting. Community Paramedicine can eliminate gaps in the care continuum as a 24/7/365 medical resource. This would not only improve the patient experience but also improve population health and reduce healthcare expenditures.  Preventative or real time care is becoming more and more accessible through programs like Community Paramedicine, Telehealth options and real time wearable tech updating providers of issues. Routine follow ups have been a great preventative resource and led to much success with our Community Paramedicine program, but gaps still exist, many centered around Social Determinants of Health, i.e. environment, education, food security, and health access. Just like when you bring your car to the mechanic and all of a sudden that irritating noise is gone, patients often feel and look great during routine visits but that time between visits is where we are seeing patient’s health plans breakdown and they return to the convenience of 911 and the hospital. As much as we educate patients to look for signs of health decline they aren’t always paying attention to the small signs and not initiating preventative care rather than reacting to acute conditions. These gaps can be reduced with real time interaction every day, in which the patient can select user friendly options that clue us into their current health and we can determine the need for additional intervention.