By Alison Cross
The Day
NORWICH, Conn. — Nearly one in five congestive heart failure patients are readmitted to Backus Hospital after discharge.
A new effort led by Backus, Hartford HealthCare and American Ambulance aims to slash hospital readmission rates by bringing specialized care straight to the homes of rural, vulnerable and medically complex patients.
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The program, which launched Tuesday at Backus, is Connecticut’s first state-designated Mobile Integrated Health program.
“This is an important step forward, and this is exactly the type of work we need to be doing … to make healthcare better, and to make it more accessible and more affordable, and to help more people within our communities live better lives,” Hartford HealthCare President and CEO Jeff Flaks said.
Flaks said the program is intended to reduce unnecessary hospitalizations and healthcare costs by bringing specially trained paramedics into the homes of patients who have recently transitioned out of the hospital.
The program is expected to serve up to 1,200 patients a year across Norwich, Montville, Plainfield, Preston, Ledyard, Sprague, Lisbon, Griswold, Franklin and Bozrah, according to the state Department of Public Health.
“I’m so proud that we’re initiating this here in eastern Connecticut … where we can reach so many people and so many different diverse communities,” Flaks said. “This is the perfect place for us to prove (its) effectiveness and (its) impact, and we will measure it so that we, over time, can scale this across all of the state of Connecticut.”
DPH said the program will provide in-home wellness checks, post-hospital care, infusion services, medication management, chronic disease management and vaccinations with a “focus on reducing hospital readmission rates for patients with congestive heart failure.”
More than 19% of congestive heart failure patients are readmitted to the hospital — the highest readmission rate of any patient group, according to a Community Health Needs Assessment completed by Backus Hospital in 2022.
Dr. Kyle McClaine, the chief emergency services and EMS medical director at Backus, explained that patients can feel overwhelmed managing new medications, navigating new diet restrictions and monitoring their own vitals once they return home from the hospital.
McClaine said that too often these patients fall through the cracks, missing blood draws and follow-up appointments until they end up in the hospital again for congestive heart failure, diabetes, COPD, asthma and other conditions.
The at-home model is designed to eliminate physical and socioeconomic barriers that make it difficult for patients to access post-operative care in traditional clinical settings.
Paramedics will work in tandem with nurses and the patient’s existing doctors to provide care that is coordinated and proactive. Paramedics will also assess home safety concerns and refer patients to food, utility and housing services through the Hartford HealthCare Connections That Matter platform.
Joshua Beaulieu, the director of operations for American Ambulance, said the Mobile Integrated Health, or MIH, program represents a shift in how the healthcare system thinks about emergency medical services.
“As EMS professionals, we definitely have a unique perspective on how MIH can be impactful in the communities,” Beaulieu said. “We see patients in their homes and in the communities. We recognize barriers to them being successful around medication management, mobility concerns (and) environmental barriers that often go unseen by other healthcare providers.”
“Traditionally, EMS has been there when a crisis occurs, and we respond quickly, we provide critical care, and we get patients to the resources that they need,” Beaulieu explained. “Through MIH, we have the opportunity to do more. We can help prevent avoidable emergencies. We can support patients in their transition from the hospital, and we can connect people to the resources that they need to stay healthy and independent in the communities.”
DPH Commissioner Dr. Manisha Juthani said the Mobile Integrated Health program started as a conversation in 2017. After the legislature passed the statutory language for the initiative in 2019, Juthani said the program sat stagnant without any appropriations.
“When I became commissioner (in 2021), in the first month that I was in this job, I got a complaint from a hospital exec about why DPH had not done anything as it related to mobile integrated health,” Juthani said. “The first thing I had to do was learn what we were supposed to be doing and why we hadn’t done it to date. And what I realized was we hadn’t been given any funding to conceptualize or set up such a program.”
Once the necessary funding was secured, Juthani said, it took some time for hospitals to determine how they would run such a program.
“Now the applications are coming in, and it really is with the greatest joy today for me to see this program that started out as a complaint … come to fruition as something that is actually going to impact the lives of people here in eastern Connecticut,” Juthani said. “This is transformation in the making.”
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