It’s a scene that’s all too familiar, a loved one finds themselves in the hospital and is diagnosed with a complex condition that changes everything. Once the shock of this event begins to set in, family and friends are left to wonder how they will handle this adjustment once they return home. For many, the real work begins after discharge. Family members are given the responsibility of coordinating follow-up visits, managing day-to-day care, and searching for additional support across the community. It’s a process that can be completely over-whelming, especially for family members who are now in the unique position of becoming the primary care giver.
In 2018, the Central New York Care Collaborative -- through their Innovation Fund – awarded $500k to St. Joseph’s Health, for the development of a Mobile Integrated Service Team (MIST). The MIST program allows clinical and community-based services to be provided to patients in their home. MIST uses a team based approach that includes service integration, patient engagement, care coordination, and cross-sector partnerships to address the patient’s medical, social, psychological and spiritual needs once they return home.
“One of the reasons we wanted to start the MIST program is because we recognized that hospitals, in general, are really good at getting people out of the hospital,” said Brenda Ko, manager for network care coordination at St. Joseph’s Health. “But the real challenge is once they are discharged, how we can keep them out of the hospital.”
The MIST program focuses on patients with complex conditions and offers home-based medical care including care coordination and case management services. This proactive approach allows patients to receive services in their homes and offers insight in to the environment, support network, and potential risks that could impact long term outcomes.
"It was like a great burden was lifted off of me."
When you enter the home of Paul and Linda Krawczyk, you’ll find a living room that has been converted to accommodate Linda’s many care needs. In addition to all the equipment and devices in the room, you’ll also be greeted by Linda’s warm smile.
In 2012, Linda was diagnosed with a complex neurological disorder. The diagnosis began what would become several years of treatment and visits to the hospital. During that time, Paul became his wife’s primary care giver. In 2018, Linda’s condition took a turn for the worse.
“In October of 2018, I could get Linda down the stairs, up the stairs, out the door, take her to dinner, that type of thing” said Paul. “Then November first, she went into the hospital with major respiratory issues. The doctors told us she was going to die. The plan was to perform a tracheotomy and then place her on a ventilator to help her breathe, then have her discharged to a nursing home in Binghamton. She's at the end of her days, they said.”
After requesting that Linda be allowed to go back home without the tracheotomy, the Krawczyk’s received a referral to the newly developed MIST program. Natalie Rivard, a family nurse practitioner for the program provides care for Linda in her home.
“We focus on patients that kind of fall through the cracks after discharge,” said Ms. Rivard. The MIST program model attempts to proactively manage issues before they result in the need for emergency care by providing home care services that can intervene the moment a patient experiences a change in condition. Ms. Rivard is part of a care team that includes two nurse practitioners, a collaborating physician, and a Chaplain, who’ve been able to offer assistance to the Krawczyks. Most importantly, the team has made it possible for Linda to stay in her home.
“It was like a great burden was lifted off of me because now I had somebody coming to the house who could communicate back to all the doctors and specialists. Without them, I would be trying to do this all on my own,” said Paul. “I’ve often wondered, how do regular people do this?”
"How can we make this work?"
The New York State Medicaid Accelerated eXchange (MAX) Series provides guidance and concepts to redesign care delivery for vulnerable patient populations. Offered through the New York State Department of Health, the MAX series provides tools that can transform care for vulnerable patients by leveraging existing resources, strengthening community partnerships and getting patients the right care at the right time. St. Joseph's Health participated in the MAX series to reduce hospitalizations for high utilizing patients. St. Joseph's work on the MAX series ultimately lead to the creation of the Mobile Integrated Services Team (MIST) program.
“The MAX series brought all the key players to the table,” said Melissa Allard, system director for home and community based services at St. Joseph Health. Allard said that once the different departments started thinking about ways to improve care for the most vulnerable patients at the hospital, it opened up possibilities to make significant changes. “When you looked around the table during our first discussions, you saw staff from home care services, case management, care transitions, emergency services, primary care, and behavioral health, all trying to figure out the best way to work together to improve services. We really started with the basic question of ‘how can we make this work?” said Allard.
From those initial discussions came plans to identify patients that used multiple services across the St. Joseph’s Health system. Once the patients were identified, the team would work to coordinate services across departments and address any gaps in care that may lead to the patient returning to the hospital.
While the work of the MAX series coordinated services across the system, it also provided insight on ways to support vulnerable patients once they left the hospital setting. “We looked at what we learned from the MAX series (and other programming), and simply asked the questions: ‘what worked?’, ‘what didn’t work?’ and how can we make a difference once these patients leave the hospital? That’s essentially how the MIST program was born”, said Allard.
St. Joseph’s Health applied for funding to implement the MIST program through the Central New York Care Collbaorative’s Innovation Fund. The Innovation Fund offers grant funding to coordinate services and improve care for Medicaid and uninsured patients across the Central New York region (Cayuga, Lewis, Madison, Oneida, Onondaga, and Oswego Counties). The Innovation Fund encourages applicants to develop creative approaches that address physical, social, and mental health needs while also fostering community partnerships. St. Joseph’s Health received a $500,000 grant for the MIST program.
“The Innovation grant really provided us an opportunity to look at how we could be more proactive in supporting vulnerable patients once they left the hospital,” said Allard.
“I could not do this without these guys.”
Providing services in a patient’s home gives you a unique perspective on more than just their physical needs. Father Charles Vavonese, is the chaplain for the MIST program, and part of the care team that provides services to patients. “When we started to work with these patients in their homes, we found that there are needs beyond physical care,” said Father Vavonese. “It truly is comprehensive. I’m part of the team and my contribution is the spiritual health, but we look at all the needs being presented to us and how we can best serve the patient.” In many instances that means picking up the slack wherever it’s needed. “I fill out housing applications for patients that need to change housing. I’ve also worked to try and secure food stamps for struggling families,” said Father Vavonese. “If it needs to be done, we do it.”
“We always try to make sure we keep the patient first,” said Brenda Ko, manager for network care coordination at St. Joseph’s Health. “Our team really attempts to find out what’s important to the patient and often times that means asking the patient directly: what’s your goal and how do we get there? said Ko. “So much of what impacts the patient has to do with the support system around them. If we can play a role in improving that support system, then we can make a huge difference.”
The benefits of the MIST program extend beyond the services they provide to the patient. They can also have a dramatic impact on the families they serve. “This is such a great program because I could not do this without these guys,” said Paul Krawczyk. “Our experience proves that there's a need out there for services like this. These guys came in and helped us with everything - appointments, medications, in-home care, everything. There is no doubt in my mind, that Linda is alive and staying strong because these guys are doing their job. Whatever it took to get them here, you need to keep doing it and doing it for more people. Because there's got to be a lot of people out there that need this kind of help.”
This whole experience has certainly left an impression on the Krawczyks. For Paul, the best part is seeing Linda smile. “What amazes me is that Linda’s attitude is off the charts,” said Paul. “People leave here and they just go, ‘I can't believe her attitude’. And I think it's because she's in her house. She's around friends and family. And these guys (MIST Team), they're no longer just a service provided to us. They are our friends and family. That's what they've become.”
(Listen to a clip of Paul Krawczyk Interview Below)