UNC Health Blue Ridge Receives $295,000 Grant for Mobile Integrated Health

During the peak of the COVID-19 pandemic, UNC Health Blue Ridge formed a Mobile Integrated Health team to visit COVID patients at home. Now, that concept will be expanded to help even more people through a $295,000 grant from The Duke Endowment.

The Mobile Integrated Health team became operational in December 2020 after doctors found that some patients being sent to the hospital for treatment could possibly be treated at home. This allowed the hospital to keep COVID admission rates low and have more beds available for sicker patients.

“The innovative concept successfully helped Blue Ridge navigate the frantic times during COVID,” said Drew Thomas, Chief Ambulatory Officer and VP of Medical Group at UNC Health Blue Ridge.  “We have seen approximately 300 patients since our program was established. It worked so well that we wanted to expand the role of the team to focus on acute and chronic diseases such as respiratory disease, diabetes, congestive heart failure, and fall prevention.”

With the grant money, Blue Ridge hopes to put more community paramedics (CPs) on the road seeing patients at home and keeping them out of the emergency room (ER) for unnecessary visits. In addition to Blue Ridge, other partners include Blue Ridge’s urgent care, express care clinics, 10 primary care offices, and emergency rooms in Burke, Caldwell and McDowell.

The program’s potential patients will be identified through provider referrals, emergency room referrals, hospital discharges, Medicare annual wellness visits, and more. 

“Once we get the referral, we will meet with patients in their homes to assess their overall health, living conditions, support structure, and other social determinants of health,” said Daniel White, CCEMT-P, a Critical Care Emergency Medical Transport Program paramedic on the mobile health team. “We will work with the patient, their primary care physician, and other care providers to devise a care management plan and to connect the patient with resources in the community.

Those resources could include home health agencies, oxygen supply companies, hospice, local food assistance, transportation, and Adult Protective Services. “Collaboration and care coordination are vital to a successful community paramedicine program,” said White. “Perhaps the most crucial role of the community paramedic is connecting underserved patients with local resources.”

While the Blue Ridge program is not the only community care program in the area, it is unique in that the mobile health team has the opportunity to work directly with the patient’s primary care provider and in some cases, specialty providers. 

“We work with them to develop a patient care plan to help them have a better quality of life, through keeping their care at home and out of the hospital,” White said. “We also are able to administer treatment in the home without having the patient go into the ER. During the COVID pandemic, we were able to offer fluid treatment and provide antibody treatment at home for patients without having them to go into the ER or infusion center.”  

The program has set several goals for the future:

• Increase the number of community paramedics (CPs)
• Have CPs see an average of 275 patients per year.
• Reduce the number of patients returning to the emergency room within 24-48 hours of their initial visit by 5% in the first year.
• Have at least 75% of A1C tests (a simple blood test that measures your average blood sugar levels over three months) completed among Humana and United HealthCare patients.

The grant will support a two-year expansion of the Mobile Integrated Health Team. “The expectation is that the program will create cost savings for both of our emergency rooms, our urgent and express care clinics,” said Drew Thomas. “This will be due to returned visits, unnecessary emergency room visits, preventable hospital stays, and readmissions.”

White points out another benefit – patient success stories. “We’ve helped several patients with diabetes with medication management, and resource management, which in turn has helped decrease their A1C levels. We have worked with patients who have Chronic Obstructive Pulmonary Disease (COPD) to help them be able to develop a better quality of life, get out of the confined space of their homes and enjoy their families once again.”

The Duke Endowment works with health systems and their community-based partners to identify, test, and spread innovative practices that have the potential for scale and sustainability. Priority is given to models that build capacity to provide essential health and social services to underrepresented communities. 

"The Blue Ridge HealthCare Foundation is honored to partner with the Mobile Integrated Health Team and The Duke Endowment on this grant," said Traci Riebel, the foundation’s executive director. "It is exciting to play a small role in helping expand such a wonderful and value program for our community and for UNC Health Blue Ridge."