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Planning Your Integrated Program

Healthcare stakeholders such as hospitals, physicians, payers, home health agencies and hospice agencies are quickly learning the impact mobile integrated healthcare programs can have on patient outcomes and care costs. That is great news, but it poses serious questions to those not yet engaged. What will you need to do to get such a program started? What gaps will you fill? What’s the right delivery model? What data should you track to demonstrate value? This article walks you through the steps necessary to strategically plan and deploy an MIH program for your community.

At Mercy Medical Center, the CFO just received the hospital’s 2015 readmission penalty notice, and it’s increased from 0.51% last year to 1.89% this year. The hospital wants to start a readmission prevention program as quickly as possible. The CFO invites local home health and ambulance service leaders to a breakfast meeting with her, the chief executive officer, chief medical officer, chief experience officer, chief nursing officer and vice president of care coordination. There stakeholders work to frame out the questions they’ll need to work through:

• What’s the problem Mercy would like to solve?

• Can a mobile resource offer the right solution?

• What is the delivery model?

• Who all needs to be involved and committed?

• What training is necessary for practitioners?

• Who will do the training?

• How will information be shared?

• What is the economic model?

• What does success look like, and how will it be measured?

Mercy develops a rapid implementation strategic plan using a “driver diagram” methodology that depicts the relationship between the program’s aim, the primary drivers that contribute directly to achieving it and the secondary drivers necessary to achieve the primary drivers.

Clearly defining an aim and its drivers enables the team to have a shared view of the theory of change in a system. It sets the stage for defining the “how” elements of a project—the specific changes or interventions that will lead to the desired outcome.

The Meeting

The next day everyone is enthusiastically welcomed into Mercy’s C-suite. Mercy’s goal is to reduce 30-day CHF readmissions by a quarter. The meeting produces the strategic plan shown on the next page. All agree that in order to accomplish it, several joint task forces will need to be formed among Mercy and its mobile partners, including groups focused on clinical matters, operations, finances, IT and compliance. The goal is implementation within 90 days.

With this plan Mercy is well on its way toward a rapid implementation strategy. Everyone agrees to have weekly program implementation conference calls and face-to-face meetings every three weeks. During these meetings the task force leaders will report progress and everyone will help with accountability. The executive task force will work through thorny issues such as HIPAA compliance, health IT integration and contracting. The cardiology and medical control leaders will meet with their constituents and get various protocols approved and contact processes resolved. The finance task force will assist with financing asset acquisition and setting up the billing process. The CMS Quality Innovation Network (QIN) participants on the clinical task force will offer assistance in developing the quality improvement and patient safety reporting processes and facilitate the reporting of outcomes to the state Medicaid office and CMS Innovation Center.

By working collaboratively with all the stakeholders, Mercy successfully launches its program 90 days after the first call. This is an amazing feat by any measure. But the greatest beneficiaries are the patients who, through team-based care delivered in their homes, enjoy fewer complications and return hospital visits. The savings this produces more than offset the costs of the program.

This article was adapted from an original article that appeared at


EMS/Hospital MIH Strategic Plan

What’s the problem Mercy would like to solve?

• Reduce 30-day readmissions for CHF discharges by 25%; 

• Improve patient health status;  

• Improve patient experience of care.

Can a mobile partner provide the right solution?

• Yes, with mobile resources, 24/7 availability and core competencies, as well as being a trusted partner in other projects and within the community.

What is the delivery model?

• Care plans developed by PCP; 

• Medical control shared between EMS medical director and PCP-cardiologist; 

• Specially trained mobile healthcare practitioners in nontransport marked vehicles providing proactive home visits for education care integration; 

• Enrolled patient 24/7 access to 10-digit medical call center for episodic needs; 

• Patients identified as qualifying for home health referred to home health; 

• Patients identified as appropriate for palliative care have (if agreed to) referral to hospice.

Who needs to be involved?

• Mercy C-suite;

• EMS agency innovations team;

• Discharge planning team;

• Cardiology team;

• Home health agencies;

• Hospice agencies; 

• Local & state EMS agency regulator; 

• State CMS Quality Innovation Network.

What training is necessary for practitioners?

• 44 hours of focused CHF management, care transitions, motivational interviewing  and the Conversation Project;  

• 20-hour classroom, 24-hour clinical rotations in CHF clinic and cardiology offices and hospice agency.

Who will do the training?

• Cardiology nurse educators; 

• Cardiologists; 

• EMS medical director; 

• Patient experience officer; 

• Hospice nurses; 

• Home health administrator.

How will information be shared?

• Face sheets faxed to EMS agency with signed consents; 

• Written record of each patient encounter sent electronically to hospital for upload to hospital EHR on shared platform with cardiologists; 

• Related scoring tools conducted by EMS agency (health status, patient experience ratings).

What is the economic model?

• Budget developed by EMS agency and approved by Mercy; 

• Mercy pays referral fee to balance EMS agency budget; 

• Bonus payment to EMS agency by Mercy if goals are met or exceeded.

What does success look like, and how will it  be measured?

• All-cause readmissions tracked by Mercy and the regional hospital council; 

• 30-day post-discharge ED and admission data reported; 

• Readmission ratio of expected to actual measured; 

• Health status questionnaires completed; 

• Patient experience surveys conducted. 


Matt Zavadsky, MS-HSA, EMT, is the public affairs director at MedStar Mobile Healthcare, the exclusive emergency and nonemergency EMS/MIH provider for Fort Worth and 14 other cities in North Texas.

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