Mobile Integrated Health is a multidisciplinary team of paramedics, nurses, and social workers who support patients and families by offering post EMS intervention, assessment, disease management planning, care coordination, disease education, resource provision, emotional support, and advocacy to ensure patients have access to the right level of care and can strive for the highest life quality they envision for themselves.
What professionals are part of MIH?
PBCFR believes that patients and families are best served by a multidisciplinary team of professionals who work in partnership with the patient/family to address all of the unique aspects of that patient/family's needs. To achieve this, PBCFR created an innovative model that includes paramedics, nurses, medical social workers, and other healthcare professionals. By approaching MIH with the understanding that every situation is unique we ensure that every patient gets the care, attention, and outcomes that they believe are right for them.
What are Medical Social Workers?
Medical Social Workers have a Master's degree in social work, and at Palm Beach County Fire Rescue, are also licensed in the state of Florida as Clinical Social Workers. Medical Social Workers have experience helping individuals and families navigate issues related to their physical and emotional health. Medical Social Workers can assess needs, problem solve, provide crisis and trauma care, identify resources, create plans of care, provide counseling and emotional support, educate, and also advocate. Medical Social Workers have compassion and expertise in issues related to adjusting and living with chronic medical issues and have advanced skills and knowledge on connecting identified needs of individuals with solutions and resources to enhance their quality of life.
What are Community Paramedics?
Community Paramedics are licensed paramedics in the state of Florida and have specialized training to offer medical evaluation, medical intervention, advocacy, and disease specific education to ensure the health needs of individuals are met as part of a Mobile Integrated Health contact. Community Paramedics go beyond their advanced lifesaving skills to evaluate and assist in creating care plans to help individuals and families navigate chronic disease management challenges that may be impacting life quality and an individual's ability to function.
How are MIH patients selected?
Patients who may benefit from MIH are identified by data indicating they meet criteria for one of the MIH programs and through referrals from our PBCFR crews who identify a need during a 911 call.
Are patients automatically enrolled in MIH?
PBCFR believes in the patient's right to make their own health decisions. When a patient is identified as being a candidate for MIH, our team reaches out to explain our programs and how we may be able to help. If the patient is in agreement, we complete an enrollment package to ensure the patient is involved every step of the way.
What types of programs does MIH offer?
High Frequency Utilizer Program: This innovative program is designed to ensure patients are receiving the care and resources they need to reduce their reliance on EMS. Patients who enroll in this program will receive in home visits and telehealth support for 30 days while they partner with the MIH Team to determine what their needs are and how to best meet those needs based on their unique strengths and challenges. The goal is to connect these patients with community based services and partners within the healthcare continuum so they receive the right level of care to most effectively support their medical and psychosocial needs.
Chronic Disease Management Program: The intent is to empower patients living with chronic disease to avoid frequent use of 911 and readmission after hospitalization by MIH serving as an extension of the hospital, their physicians, and involved home care agencies to ensure a positive transition from the hospital to home or to a plan of care that the patient's physicians are recommending. By offering health education, disease management strategies, and supporting the patient's adjustment to their chronic disease, MIH is able to serve as a partner within the healthcare continuum and empower the patient to successfully manage their health so they can maintain the highest life quality possible.
Addiction Program: This telehealth program is aimed at reaching out to individuals who have recently experienced an addiction related 911 call and may benefit from emotional support and connection to addiction intervention resources. Patients receive a telephone call after their 911 encounter from a specially trained paramedic who offers compassion, understanding, addiction education, and an entry point to medically supervised addiction care.
Crew Referral Program: This program allows PBCFR paramedics the opportunity to refer patients and families for post EMS follow-up care when they determine a need exists beyond the emergency medical care they provide on scene. The MIH social worker contacts the patient/family and works with them via telehealth or in-person to assess needs, connect them to resources, provide support, or assist with problem solving.
Pregnancy Outreach Program: This program is intended to help connect pregnant teens and women to prenatal care and pregnancy/childbirth resources to support the health of both mom and baby, and reduce the risk of complications and/or fetal demise. Patients receive a telephone call after their 911 encounter for a specially trained paramedic or medical social worker who offers non-judgmental support, prenatal care education, and an entry point to the Healthy Mothers, Healthy Babies system of care to be screened for programs that may support them. Patients who are identified as having experienced a pregnancy loss are connected to postnatal grief care in partnership with VITAS Bereavement Services.
CARES Fall Intervention Program: This unique program allows a professional volunteer team of social service and health professionals to respond with crews to 911 fall calls in an effort to provide immediate fall intervention support to patients and their caregivers. The CARES Team completes a fall risk assessment, home safety assessment, and also connects patients to data driven home health fall intervention programs.
How is MIH different from a home care agency?
Mobile Integrated Health does not provide the services of a home care agency, but rather, MIH identifies the need for and connects patients to home care services to ensure their nursing and therapy needs are met. MIH is a partner to home health by advocating for home care involvement with physician and discharge planners. MIH is in a unique position to see the home environment and how the patient functions within it. This allows MIH to effectively assess home care needs and request orders that will enhance the patient experience and improve patient outcomes. By remaining in the patient's home for up to 30 days, MIH can ensure the home care agency receives orders to start care, and that any challenges that arise with referral to home care are navigated in a way that supports the needs of the patient. When the entire health care continuum works together we improve the patient experience and set patients on a path to successfully managing their health and wellness needs.
OTHER LANGUAGES