Vital signs


How Mobile Integrated Healthcare keeps patients thriving and out of repeat visits to the ER

Oct. 10, 2018 — “How are you feeling?” Chris Martin, a paramedic for the new Mobile Integrated Healthcare program that is being tested in the Siuslaw region, asked as he crouched next to the armchair. He sat down his paramedic bag, looking through.

“I feel pretty good,” replied David Hole, who was resting in the chair. It was the Holes’ home, and Martin had come by for a regular visit. “My legs still aren’t back, and I have days like today.”

Martin asked how the pain was going, what medications he was on. Then the big question: “How is the walking going?”

David laughed, expecting the question.

“Oh, I’ve been naughty,” he said.

“Not so well?” Martin asked?

“Naughty, naughty, naughty,” said David.

David explained that his wife, Pat, had come down with a cold recently and wasn’t able to go for walks with him. To help heal from his back surgery, David is supposed to walk frequently, keeping his muscles from atrophying and allowing his back to remain strong. Generally, he walks around the neighborhood, but he hates to walk by himself.

“I know, it’s no fun,” Martin said.

“It isn’t fun anyway, but it’s less fun by yourself,” David said. “And I get concerned that I get over there with my walking sticks, fall down, and nobody can help me.”

David explained that he always has balance issues with his leg being weak.

“Today, they’re really weak, and I don’t know why,” he said. “

David first met Martin five months ago.

“Up until 2015 I was pretty damn healthy,” David said. “Then I had salmonella. Then a resulting aneurysm. And then I had open heart surgery. I think that’s what I got trapped in, it really affected my legs. Before I ever recovered from that, BAM, another back surgery.”

It was the reasons for the back pain that kept him confused. He had gone into the emergency room (ER) three times because “they couldn’t give me answers.” He was told that it could be a urinary tract infection, then pancreatitis. But the remedies didn’t seem to be working.

After the third ER visit, Pat got a call from the hospital.

“Someone said they had started this new program,” she said. “They knew we had been in the ER, and they have this follow up procedure. Would we like someone to come by? I thought, ‘Hey, another resource.’”

“And it’s free!” David said.

So, Martin came over to David’s home. He checked the home for safety, looking at everything from rug placement to if the smoke alarms worked. With David’s medical history in hand, Martin was able to see exactly what David needed to be working on, and make sure that he was following through. Martin has been coming to the David house ever since, checking up on him, answering medical questions. David hasn’t made another trip to the ER.

They’ve also developed a friendly, comedic banter.

“We’ve formed quite a partnership here, Chris and I,” David said. “Chris is good for me because my wife is a wonderful person, and I love her dearly, but he always brings something in from the outside. It’s just Pat and I; our children are all grown and gone to other states, even. It’s nice to have that interaction for me.

“We don’t have a lot of friends that come in. They’re dying. I swear to God, they’re all dying. You hear that death happens in threes. That guy died, and then that guy on that corner died. And up here. That’s three. Thank God I’m safe. I made it through, you know?”

 “How much is an old guy’s life worth?”

Earlier in the day, Martin was just beginning his shift for Mobile Integrated Healthcare.

Beginning early this year, Western Lane Ambulance District partnered with PeaceHealth Siuslaw Region to create the program. It provides in-home services to three types of patients: 30-day readmissions, ER high utilizers and Emergency Medical Services high users.

Martin is the only paramedic working in the pilot program, which is completely funded through a $200,000 donation from Peace Harbor Medical Center Foundation. No insurers are billed, and the patients never pay a dime.

The goal of the program is to help curtail expensive emergency and medical expenses for the hospital and the patient by keeping frequent ER trips down.

It’s not home healthcare, Martin said, and it isn’t a permanent fixture in most of these patients lives — though he has been seeing some regularly for months.

“They’re just checkups to go in, see their vital signs,” Martin said. “See how everything’s going. Make sure the house is in good shape, if there are any problems I see.”

If the program is successful, it could become a permanent fixture in the Siuslaw Region. Other areas, such as Eugene, are closely monitoring the Mobile Integrated Healthcare program to see if it can be integrated into their own healthcare system.

How the program chooses patients begins at a daily morning meeting at PeaceHealth Peace Harbor, where patient discharge planner and medical social worker Mary Anne Carter goes over the roster of current patients with Martin.

“We have a daily worksheet and we print out patients every day,” Carter said. “We have categories that are important to us, such as if they were readmitted. We try and focus on COPD (chronic obstructive pulmonary disease), diabetes, heart failure. Those are the ones that seem to have the most return to the hospital, especially COPD. They’re at the home, they can’t breathe, they start to panic, they can’t breathe even more, they go into the ER.”

Carter said that they do have a home health agency that can help, but its time is limited.

“Chris is like a free agent,” Carter explained. “He has the option to just go in there, sit and talk with them. Develop that rapport that makes them comfortable, so they don’t come rushing to the ER. Statistics have shown that patients who return to the ER frequently, it’s traumatizing for them. It’s really better to keep them at home, unless it’s an emergency. Of course you come to the hospital then. But an emergency room is very traumatic for an elderly person.”

Martin added, “And some patients are afraid to go into the hospital because they’re afraid they won’t come out of the hospital. This way, I can go out there and talk to them in their home and assure them.”

After Carter, Martin and other healthcare professionals at PeaceHealth choose which patients are best suited for the program, the program inquires if the discharged patient is willing to meet with Martin. A visit from the Mobile Integrated Healthcare Program is not mandatory, with patients having the final say if Martin visits or not.

“Sometimes they don’t want me to come out, and sometimes they do,” Martin said. “It just depends. It’s frustrating at times, because I can help them, but they’re not accepting the help.”

Carter explained that the patients who primarily use Martin’s services are very private.  

“The retirees worked hard to get where they are, and they’re very independent,” she said. “To depend on somebody is giving up some of their freedoms, and they don’t give in easily. People think that we’re going to come into their home and take away rights, say, ‘You can’t live here.’ They really feel like we’re infringing on their independence, and that we’re going to take it away from them. But, that doesn’t happen with us.”

Most who have opted for the program have ended up appreciating it.

“It took us two months to see this one person,” Martin recalled. “She ended up loving it. She came in bragging about it at a community meeting.”

While the group has yet to gather exact statistics on the program’s efficacy, anecdotal evidence points to a drastic decrease in readmissions since the program began.

“You can see the readmissions were higher last year than they are now,” Martin said. “Having a true number, I can’t have that. I’ve had 400 visits, though.”

It’s impossible to say if the program prevented 400 hospital visits, but if it had, the savings to the hospital could be worth millions, since the average ER visit costs $8-10,000, according to Martin. Four hundred ER visits could cost up to $4 million.

Insurance companies save money in covering costs, and patients save money in copays.

David saw the high cost of healthcare when he went into the ER for salmonella, which he nearly died from.

“I was so sick,” he said. “I thought, you know, how much is an old guys life worth? I really thought that, especially when I got the bill later from the hospital. $178,000. I told Pat. She thought I was kidding. Seriously, I thought I wasn’t worth that at my point in my life. I was 75.

“I’ve changed my mind now. I’m going kicking and screaming.”

 “A little undercover work”

As Martin drove to David’s house for his checkup, he went over what an average home visit consists of.

“They’re usually anywhere from 20 to 90 minutes,” he said. “The first visit is always the longest, as we go through their medications and make sure they don’t have questions about the medications. Why they’re taking it, how long they’re taking it. If they have any equipment, they can ask me how to use it, how to clean it. All of that takes a lot of time.”

He also does a thorough inspection of the house, ensuring a safe environment: Handrails are secure, rugs are not slippery, make sure the steps aren’t creaking and crackling.

“I’ve found smoke detectors that aren’t working,” Martin said. “Get those replaced, talk to the fire department so they can go out there and get them replaced through a program they have. That’s up to 25 detectors that I’ve found. People don’t have fire extinguishers in their home, so I go out and get one, show them how to use it. Make sure they have food there, and that they’re eating the right type of food. Make sure the house is clean.”

For subsequent visits, Martin does the usual round of checkups, taking the patient’s vitals, and answering any questions.

“When you’re in the hospital, there’s so much going on and you just want to go home,” he said. “And with everyone talking to you, it’s possible you still don’t understand. Or sometimes they forget to ask a question. They can ask me. If I don’t know the answer, I can get it.”

Sometimes Martin visits a patient just once, but the majority see him four or five times.

“There are some people that are probably around 40 visits,” he said. “But whenever I stop seeing them, they’re coming back to the ER. And so, we found that if I spend 30 minutes of my time, I can prevent them from coming to the ER when it’s not needed.”

Right now, Martin is seeing anywhere from 45 to 60 patients, visiting around five a day. During his 10-hour shift, he also helps fill in the gaps in the healthcare system.

“I’ve really helped palliative care a lot,” he said. “Really helping Home Health out when they’re falling behind. The Care Coordinators will call, having concerns with a patient that they can’t get a hold of. Or some lab was out of whack and they can’t get a hold of them. They’ll call me, and I’ll go out there and talk to them.”

The vehicle he drives is rather nondescript; one would never know a patient is getting a visit from the hospital.

“The original plan was to show up in an ambulance, but people get panicked, wondering if someone is hurt,” he said. “It attracts too much attention. You have to do a little undercover work.”

 “Quite a little bond”

After asking about walking, David began describing his medications. Then it was back to the walking questions.

“How far are you able to walk?” Martin asked.

David described walking down to the end of the street, his normal loop that runs about a mile. But he hadn’t been to the gym in a week.

David started walking around as Martin watched. While he didn’t use his canes, he was still able to get up, but he was noticeably uncomfortable walking.

“Even walking over here, you’re still off balance a little bit,” Martin said.

“Some days,” said David. “I don’t know why my balance is such an issue today, other than … Maybe a hangover from that medication.”

“Which is why you need the stick. I know you don’t want to use a walker,” Martin said.

“I just hate that walker, you know?” David interjected.

“But is it better to use that than fall over and break your hip?” asked Martin.

“Well, of course it’s better than a broken hip,” David answered. “But, I don’t like the walker. I’ve gotten so lazy with that walker. I go brush my teeth, and take my walker, and lean on it. How damn lazy can you be, you know? It’s a matter of me standing there and my legs being not that strong. But that’s an excuse.”

“It is. You’re losing muscle,” Martin said. “And the more you sit, the more muscle you’re going to lose, and the more out of balance you’re going to get.”

David tried to say that the balance wasn’t an issue, but his wife shook her head.

“Hey, you gotta decide whose team you’re on here,” he said.

She laughed, saying, “Well, honey, you tell me all the time your balance isn’t good.”

“It’s not great, but for what I’ve been thorough…”

“You’re doing awesome for what you’ve been through,” Martin said in agreement.

When David first Martin, he could hardly get out of bed. David was in the ER the previous night and was still groggy in the morning.

“I was sleeping so soundly, and I didn’t know what was going on. It was like I was drunk, but I don’t drink anymore. I used to enjoy a good glass of wine, but now it screws up my balance,” he said. “That’s bad when you live in red-wine country. That’s terrible.”

“I helped you out of bed,” Martin recalled. “And you walked out here (to the living room) with your walker.”

“It was not good,” David said. “I’m sure Chris said, ‘I don’t think I’ll come back there again.’”

“Oh no, not at all,” Martin said. “We’ve got quite a little bond.”

David credits Martin, including his persistent reminding of walking, for his recovery.

“It’s because Chris has been real straight with me,” David said.

Martin took David’s vital signs and talked more about medication.

“Do you want me to come back next month?” Martin asked. “It’s up to you. I’d be happy to come back out. If not, you have my number.”

“I always enjoy the exchange, if you want to come back out,” David said. “Give Patricia the date, and we’ll get you on the calendar.”

David didn’t have any upcoming doctors’ appointments, so it was decided Martin would come back to check on vitals, and to make sure the balance issues weren’t getting worse.

While Martin went to schedule the next appointment with Pat, David talked about his experiences with the local medical system.

“We’re lucky here,” he said. “I think it’s a good hospital, and for the most part you get good care. Pat and I are lucky. We’ve probably got, I think, the best primary care physician in the area, and that’s Aaron Holmes. He is so awesome, and he doesn’t quit. I hope he doesn’t do like the other doctors and leave.

“I know they’re trying to get good doctors in there. It’s hard getting into a community like this, unless you want to do geriatric medicine. Medicine here is tough.”

 “They’re doing okay”

 As Martin was leaving the house, he egged on David once again to keep walking.

“Make sure you use the sticks,” he told David.

David said he would.

“He’s a talker, and he’s hilarious,” Martin said as he drove back to Western Lane Ambulance. “The visit went well. First time I saw him, he could barely walk from the bed 10 feet to a chair. After the surgery, he was using the walker inside his living room. Six weeks later, he was able to take it down to the end of the road and back. He was up to about three-quarters of a mile, three or four times a week.”

As for the strictly medical part of the visit, there wasn’t much to report. The vitals were good, there were no dangers around the house. Still, the visit took an hour.

“A big part of my job is the social aspect, particularly people out here who are retired,” Martin said. “They’re in their home and they don’t get out. One of things I do is encourage them to go out to places, see people and get involved. There’s a senior center, with lunches to go out to.”

But what about patients like David, where mobility is an issue?

“There’s also places that will come out and give rides to places,” Martin said. “We just need to get them out and about. Today became a lot less medical and more social. Just making sure he can get stronger and better.”

For Martin, the social aspect of the Mobile Integrated Healthcare program is key to understanding why it works.

“Depression leads to a lot more medical problems, which leads to a lot more visits to a doctor’s office,” he said. “That leads to more money for them to have to pay out after insurance. If it takes me going out and talking to them for a few minutes, then I have saved money. It saves the patients’ money, as well as the insurance company and the hospital. By just going out there and talking to them.

“A lot of people just want reassurance that they’re doing okay.”


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