Strategic Directions for Mobile Integrated Healthcare in Region VII

Introduction

On Aug. 5, 2024, a group of around 40 people gathered in Kansas City, Missouri, for a strategic thinking session around mobile integrated healthcare (MIH). In practice, MIH programs and services may take many forms — but often leverage the skills and expertise of emergency medical technicians (EMTs) and paramedics to provide non-emergency and preventative services in patients’ homes.

Background

Participants came from each of the four Health and Human Services (HHS) Region VII states — Iowa, Kansas, Missouri and Nebraska — as well as from national and regional partners. They represented state associations, foundations, state health departments and other groups involved in shaping the policies and system guiding healthcare in the region. With facilitation by the Kansas Health Institute (KHI), the group discussed current strengths and weaknesses of MIH, shared partnership opportunities and identified potential next steps for leveraging MIH in the region.

The session yielded nearly 100 pages of notes, feedback and ideas. This summary aims to capture the main insights from the session and support continued discussion and collaboration around MIH in HHS Region VII.

Key Factors

The growth, sustainability and effectiveness of MIH in HHS Region VII will be shaped by numerous interconnected policies, initiatives and programs. Across these forces, five factors — two cross-cutting and three topical — stood out as key areas of focus among the leaders and decision makers participating in the strategic thinking session (Figure 1).

The two cross-cutting factors — collaboration and standardization — were undercurrents present across a wide range of MIH policy, practice and program considerations. As MIH moves forward in the region, collaboration and standardization, in a variety of forms, are likely to be important tools for driving the evolution of the model.

The three topical factors — workforce, data and funding — represent the three areas where collaboration and standardization are most likely to be directed to support the long-term growth and sustainability of MIH programs.

Areas of Strength

Multiple successful programs implemented within Region VII have demonstrated the potential for multi-organization and cross-sector collaboration within MIH. These successes, and the efforts of committed leaders and organizations in the region, have established the foundation of a collaborative approach toward MIH. Across varied sectors, participants expressed a shared desire to improve healthcare access and outcomes and an increasing openness to the role of MIH in supporting that aim. While not universal across all states and communities, meaningful relationships have been established across disciplines, partners, departments, organizations and networks. As a result, there is a growing number of stakeholders with diverse perspectives who are willing to collaborate on this initiative. The region is already seeing momentum, as partners and stakeholders have begun having conversations, sharing strategies and successes, and working toward systems that support a collaborative approach.

Areas for Improvement

Despite the collective momentum, participants identified a few key challenges that should be considered as the region moves forward. Key potential stakeholders and collaborators — including hospitals, behavioral health and substance use disorder (SUD) treatment providers — may have been underrepresented in past conversations and collaborations. Failing to meaningfully engage and collaborate with these partners risks leaving mutually beneficial partnerships unexplored, or worse, failing to identify and mitigate negative impacts on partners. The potential for MIH programs, through a reduction in emergency department visits, to negatively impact the financial position of rural hospitals was specifically raised during the session.

These concerns can only be identified and effectively mitigated through consistent and meaningful collaboration across sectors. Siloed decision making poses a continued challenge for collaborative efforts in the region, emphasizing the need for a clear avenue for communication, particularly across sectors and jurisdictions.

Areas of Strength

While a lack of standardization was often brought up as a limiting factor for MIH, some areas of strength also were identified. Across the region, the existence of numerous MIH programs operating in different settings, with different financing and with different scopes of practice all provide evidence of the potential for these programs. The measurement and demonstrated effectiveness of MIH programs varies, in part, because of the current lack of standardization across the region and within individual states. Additionally, the relative lack of standardization within MIH programs may allow for greater tailoring of MIH programs to existing local contexts and needs.

Areas for Improvement

Currently, MIH is relatively unstandardized in the region — and this lack of consistency was seen by participants as a weakness or barrier to the growth of MIH. Foundationally, states differ in their approach to defining MIH and establishing the scope of services MIH clinicians may provide — with most not specifically defining and scoping the role of MIH professionals. Participants noted the potential for standardization of definitions and scope of practice to support consistency across programs and facilitate the development of reimbursement pathways. Similarly, a lack of standardization was seen as a weakness within MIH data collection and data infrastructure, contributing to poor data collection and data sharing among current MIH programs. On the education and training side, while training curriculums and programs have been developed at the local level for some programs, they are not universal within states or across state lines. Similarly, credentialing for MIH professionals is not available in most states and not recognized nationally. Taken together, the professional pathway for EMTs and paramedics to become community paramedics is unclear in most locations and not consistent across jurisdictional boundaries.

Areas of Strength

Overall, session participants noted there is a strong commitment within the EMS workforce to embrace these expanded roles, and several states have started implementing standardized training for MIH professionals. This standardization could enhance the quality of care and ensure that services are delivered consistently. Many EMTs and paramedics are motivated to participate in MIH programs, and collaboration among state associations, healthcare providers and other stakeholders has helped to build support for these efforts. Some programs in the region have built collaborations to support workforce development and training, while demonstrating the ability of MIH to improve access to care.

Areas for Improvement

One of the key challenges noted by participants is the EMS workforce shortage, particularly in rural areas where volunteer EMS agencies face difficulties recruiting and retaining staff. A lack of standardized education and credentialing for MIH providers may also limit the ability of programs to scale and maintain consistent quality across regions. Additionally, participants noted the need to manage potential staff burnout, as EMTs and paramedics balance their traditional emergency roles with MIH responsibilities.

Areas of Strength

Throughout the region, there are existing models for data gathering and sharing that could serve as a starting point for developing a regional approach to data collection. Participants described how some MIH programs have successfully leveraged existing data collection efforts and measures to demonstrate their impact.

Areas for Improvement

Currently, data collection efforts for MIH programs are not standardized, or regularly shared beyond the individual program level. Session participants described a need for regional data that demonstrates the impact of MIH programs and services and supports informed, evidence-based decisions about the MIH model in the region. Overall, MIH stakeholders and partners could facilitate improvements by identifying who can build and design any shared data repository, who will measure outcomes, and how it will be funded and sustained.

Areas of Strength

Participants described how stakeholders, including state agencies, insurers and philanthropic organizations, have shown interest in supporting MIH initiatives — though not uniformly across all states in Region VII. While sustainable funding was identified as a continued challenge, some programs in the region have secured grant funding, partnered with a federally qualified health center or built a hospital-based program. These successes have built momentum for exploring long-term funding solutions.

Areas for Improvement

A significant barrier to the sustainability of MIH programs is the lack of reliable, long-term funding. Depending on grants or inconsistent local funding creates challenges for growth and stability. Additionally, some participants noted that current reimbursement models may not adequately cover non-transport or preventative services — particularly in rural areas where MIH could address growing gaps in service delivery.

Moving Forward

Across the varied and dynamic strategic thinking session, participants identified an array of potential strategies to move MIH forward. These strategies ranged from local, organization-specific next steps to state policy changes and national initiatives. Next, four strategic directions, with examples of specific actions, are described. These strategic directions aim to capture a range of potential actions leaders and decision makers in the region may consider.

Collaboratives and Coalitions

Participants expressed a desire to leverage the experiences and learnings of others — at the program, state and national levels. A coalition or collaboration that regularly and intentionally brings together a diverse, multisector set of policymakers, funders and leaders around MIH could facilitate this shared learning. These collaborations could be built and maintained at both the state and multi-state regional levels. By creating a regular venue for shared learning around MIH, these collaboratives could facilitate broader and more consistent engagement with stakeholders outside of EMS agencies, such as payers, funders, primary care providers, state associations, state agencies, mental health and SUD treatment providers, Medicaid offices and local healthcare leaders. Additionally, these collaborations could facilitate a stronger collective voice in policy-making discussions that shape MIH. Over time, and with the appropriate infrastructure, a regional technical assistance center could be developed to support the implementation of strategies and tools identified by the region. A multi-state collaboration would also provide helpful foundational collaboration to explore cross-jurisdictional efforts — such as standardized curriculums — that are co-developed and implemented in multiple states. No matter what level of potential collaboratives and coalitions are developed, they will require dedicated champions or facilitators with the skills and resources necessary to maintain momentum and collaboration over time.

Enhanced Data Collection and Sharing

The lack of consistently collected accurate and shareable data was noted as a key barrier to the growth and sustainability of MIH. Partners and stakeholders could collaborate to develop a regional approach for data gathering and sharing, including standardizing required data elements, developing a shared data platform and identifying how the system will be managed and by whom. Better data collection and sharing also could support partnership development with other healthcare entities by providing information needed to design mutually beneficial arrangements. Data availability and interoperability are not unique challenges to MIH, but they are particularly acute. Programs may be built or implemented within a variety of settings, including fire departments, hospitals, etc., and connect with numerous other service agencies and entities — each with their own data collection system and approach. Recognizing this challenge, strategies that work to better leverage existing data, standardize new data collection and enhance data sharing will likely play a key role in limiting or driving the growth of MIH programs. By enhancing data collection and sharing, the region will be better equipped to evaluate and improve existing MIH programs and, crucially, strengthen the demonstration of success needed to drive policy change and investment at the state and federal levels.

Established Training Programs and Credentialling Pathways

The limited number of trained, available professionals to grow and sustain MIH programs was a consistent concern identified by session participants. Developing clearer standards for education curriculum, professional testing and credentialling, and scope of practice for MIH professionals — at the national, regional or state levels — could create more effective and sustainable workforce development. Integrating supplemental MIH training into existing education programs — such as EMT or paramedic courses and programs — could support the development of a new generation of healthcare professionals who are well-prepared for these expanded roles. Stakeholders also could explore opportunities to partner with local health systems and educational institutions to build new training programs that add to existing healthcare career pathways. More clearly defined roles, skill sets and practices also may facilitate collaboration with other healthcare providers and reduce tensions and conflicts that can arise from perceived competition. Finally, efforts to standardize training and credentialling of MIH professionals may provide additional legitimacy to MIH services, thereby supporting efforts to develop sustainable funding and reimbursement.

Sustainable Funding Models

The most common weakness identified across MIH programs in the region was funding. Strengthening partnerships with local health systems and funders who share a commitment to ensuring access to high-quality healthcare could provide additional resources to support new and existing MIH programs. These partnerships and funding support could be catalysts for developing and testing new programs and building the knowledge and evidence base necessary to pursue more expansive reimbursement pathways. To create a more sustainable financial model for MIH, developing reimbursement mechanisms that cover a wide range of services, including non-emergency and non-transport care, may be needed. Engaging state Medicaid programs and private insurers in discussions about reimbursement options are two distinct avenues for securing more sustainable funding, but those opportunities may be shaped by success in other strategies — such as data collection and credentialing. Exploring an all-payer model and leveraging federal cost-sharing through a Medicaid Section 1115 Demonstration or State Plan Amendment could help secure more stable sources of funding. Ultimately, though MIH programs have a wide range of potential funding sources — from local grants to public reimbursement — establishing more consistent, stable and predictable funding may be needed for MIH programs to thrive over the long term.

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Support for this work was provided by the Washington County Mobile Integrated Healthcare (MIH) Network® d/b/a Sho-Me MIH Network, a nonprofit network comprised of diverse public and private partners working together to improve healthcare access and patient outcomes through MIH in rural Missouri. Additional support was provided by the United Methodist Health Ministry Fund, a statewide health foundation working to improve the health of Kansans since 1986. Financial support was provided by the Health Resources and Services Administration (HRSA) and the U.S. Department of Health and Human Services (HHS). The Kansas Health Institute retained editorial independence in the production of the report and its findings. Any views expressed by the authors do not necessarily reflect the views of the Washington County MIH Network® or their partners, HRSA, HHS or the U.S. Government.