Care Coordination
Health Quality Innovators QIN-QIO Builds Community Connections to Improve Health
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When health care services are not easily accessible in a community, people often call 9-1-1 or visit a local emergency room for their care. In Maryland, Health Quality Innovators (HQI) – the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) serving Maryland and Virginia – is connecting organizations within and across local communities to better coordinate care for seniors.

Trivergent, an organization HQI is working with in western Maryland, expressed an interest in starting a Mobile Integrated Health Program (MIHP) to provide patient-centered, mobile health care services to people outside of the hospital. These services include providing chronic disease care management and post-discharge care coordination, and offering care advice to 9-1-1 callers instead of dispatching emergency medical services (EMS) to their location.

HQI, which is working with organizations in Montgomery County, Maryland, was able to connect Trivergent with Montgomery County Fire and Rescue. This group of EMS professionals has spent two years tracking 9-1-1 calls from senior high rises for the WISH Program and has developed a program called MCNIC³ which targets high-utilizers of 9-1-1 systems and connects them with proper resources. Montgomery County Fire and Rescue shared their experience and lessons learned in a meeting with Trivergent, along with EMS teams from nearby Washington, Allegany and Frederick counties. When Trivergent was ready to begin their MIHP program, HQI helped identify areas of high hospital admissions and readmissions in Washington, Allegany and Frederick counties to give the EMS teams a starting point for tracking their 9-1-1 calls. Trivergent is now in the process of expanding their MIHP by involving home health organizations.

HQI also was able to help Montgomery County Fire and Rescue with its expansion of services to frequent users of 9-1-1 for non-emergencies. Kelly Arthur, one of HQI’s Improvement Consultants in Maryland, invited Montgomery County Fire and Rescue to attend a Health Enterprise Zone (HEZ) meeting with another HQI partner, Totally Linking Care in Maryland (TLC-MD), based in Prince George’s County. The HEZ is using community health workers to follow high-risk patients in its area and connect them to various programs and organizations to address their social determinants of health. The connection Arthur made between Montgomery County Fire and Rescue and TLC-MD also had a positive outcome for the people of Prince George’s County; TLC-MD asked two of Prince George’s County EMS staff to take the Community Health Worker course offered by the Prince George’s Health Department so EMS responders can be better prepared to address their patients’ social determinants of health and refer them for appropriate services.

Recently, Montgomery County Fire and Rescue received the Congressional Fire Service Institute’s Excellence in Fire Service-Based EMS Award for 2016 for its MCNIC³ program.

This collaborative approach demonstrates how technical assistance from QIN-QIOs helps communities identify the root causes of readmissions, analyze local data and choose effective, community-level interventions.