Mobile Integrated Health Care working to reduce ER visits and hospital stays, while keeping patients healthier and safer in their own homes
“People don’t realize how important it is to know your patient, to see them in the home and to learn what the barriers are,” said Tammy Church, RN. “One encounter can’t tell you the whole story.”
Through a grant awarded to the Cheyenne County Clinic in St. Francis, Kansas, Church and the EMS director Reid Raile began the mobile integrated health care service, working with high risk patients (patients at risk for complication or admission) in 2016. Church had two goals - to help patients stay safely in their homes and to reduce the number of avoidable emergency room and hospital visits.
“There are so many barriers to care that you can identify if you visit a patient’s home. But first,” Church said, “you’ve got to earn their trust. I’m not going into their homes to take over their life. I just go in with the education. We come up with a care plan and set up a routine. I find frequently that people don’t take their medication as prescribed.”
Church has worked with about 40 patients. Typically they start out with frequent home visits and then transition to semi-monthly or monthly home visits. Eventually they may only require a follow-up phone call to ensure that their care plan is being followed.