Mobile integrated health closes health care gap in Monticello

On a Sunday morning in February of 2021, Jean Barnes went early to church with her husband Skip not far behind. She kept her phone off and never saw Skip call for help after slipping and falling in their driveway.

“At that point, we think he passed out because it was an hour from that time until he called my son who… lives five, six miles out of the way,” Jean Barnes, 78, said. “I bolted down to get home before the paramedics but they had gotten here… he was very noticeably in tremendous pain.”

Doctors treated the 93-year-old Monticello man for his broken hip before he went to a rehabilitation facility and returned home with the help of home health aides. 

But what really made the difference in Skip’s recovery was Nick Green.

“I couldn’t ask to be treated any better,” said Skip Barnes about his health care. “But it was still nice to be home, especially when it was with him.”

Green is Monticello’s first mobile integrated health director and Skip was his first patient. Once the hospital discharged Skip, the health system shared his information with Green for follow-up care. His version of community paramedicine seeks to reduce hospital readmissions for patients like Skip by proactively checking in, assessing patient’s needs and connecting them to resources. 

“As comforting as it was to have home health care take the blood pressure, change the dressings on the wounds and so forth – at some point that has to end,” Jean Barnes said. “But when they’re gone… Nick’s visits continued. And that comfort eases you back into normal life because you’re not left out in the cold.”

What is mobile integrated health?

According to the Indiana Department of Homeland Security, mobile integrated health is a patient-centered model of care that occurs in a patient’s home, with a traveling unit or via telehealth.

More than half of Indiana’s counties have some form of mobile integrated health.

Transitioning from his role as a paramedic with the Monticello Fire Department to launching the city’s mobile integrated health unit came easily to Green, who said the vast majority of emergency calls were medical.

“Eighty-six percent of the time, it’s not Kroger on fire. It’s Mrs. Smith who needs an ambulance,” Green said. 

Green credited the mayor of Monticello, Cathy Gross, for bringing the idea to the city after seeing a similar effort in Crawfordsville. Green spearheaded a pilot program with IU Health – whose White County Memorial Hospital is visible from the fire department’s back parking lot – to refer discharged patients to Green for follow-up care.

After six months, not one of the 50 patients in that pilot program had to be readmitted to the hospital. Now, Green’s caseload includes 90 patients and spans over 400 house visits – many of which bleed into hours-long conversations.

“That’s 400 times our neighbors didn’t have to seek health care at a hospital or go to the doctor’s office to wait 40 minutes for a three-minute appointment,” Green said. 

During his visits, Green does routine medical screenings like monitoring someone’s blood pressure but he also checks that patients have transportation to their health care appointments and adequate food. His clients, almost all of whom are elderly, sometimes need help setting up grocery deliveries or other technology – like the life alert system he set up for Skip Barnes after his fall.

Sometimes though, Green’s most important job is to listen – whether it’s a stomachache, loneliness or something more serious. Each of his 90 patients has his cell and knows they can call or text at any time. 

“A lot of times people will call me rather than traditional 911,” Green said. “Sometimes that solution is going back to the hospital but a lot of times those solutions… (are) a simple checkup and letting that person know that somebody cares about them.

“You’re not falling through the cracks and we’re here to help you in any way, shape or form.”

Filling the gap in maternal, infant health care

Grant funding of $250,000 from the Indiana Department of Health helped secure Green’s first-ever hire nearly a year ago: Courtney Dyer, a registered nurse with a background in obstetrics services.

Dyer worked at White County Memorial before it closed its OB unit a decade ago, commuting to the next nearest labor and delivery unit at IU Health’s Arnett Hospital in Lafayette – roughly 30 miles and nearly 40 minutes away.

“Taking care of mothers and children is my passion,” Dyer, a mother with three young boys, said. “Now I’m just paid to do what I’m already doing with my friends, it’s just with strangers.”

Dyer said that she saw herself as an extension of health care services, not a replacement for prenatal visits or a physician. 

But in Monticello, one of many Indiana communities without a birthing center, she plays a crucial role in closing the health care gap in a state with one of the worst maternal and infant mortality rates in the country.

Dyer visits parents at any point of the pregnancy and guides mothers through the first four months postpartum. Week-specific education, learning to count a baby’s kicks and monitoring a baby’s development are crucial to the health of both the mother and the baby.

“If we can teach her to know those habits… she can know when something has changed and potentially save her baby’s life,” Dyer said. 

In particular, she helps mothers adjust to life at home without 24/7 support and answers their questions about whether a concern is life threatening or something that can wait until the doctor’s office opens at 8 a.m.

“It just gives them an open line to a reliable source of information instead of hopping onto Google – which will make anybody feel like they’re dying,” Dyer said. 

She shared the story of a new mom who couldn’t understand why her newborn wasn’t gaining weight despite consistent bottle feedings. She told Dyer she was giving the baby 15 milliliters of fluid, as instructed by the nurses at Arnett Hospital, and she was “terrified to overfeed” her child.

Because of Dyer’s experience at the hospital, she knew the nurses meant for the 15 milliliters to only occur for the first feeding due to the small size of an infant’s stomach. During that hectic post-delivery period, Dyer surmised, the new mom thought that was supposed to be every feeding.

“We were able to sit and just talked about appropriate amounts for feeding the baby and what that would look like. She immediately made a two-ounce bottle, the baby sucked it down and fell sound asleep,” Dyer said. “Mom was doing the best that she could with the information that she had… but we were able to address that before it became an issue.”

Making the unit sustainable

For now, the mobile integrated health program in Monticello relies heavily on city and county funding, the Indiana Rural Health Association and partnerships with federally qualified health centers alongside grants from IU Health and the state.

“Grants are great but grants aren’t forever; it’s hard to create a five-year plan when you only have a one-year plan of money,” Green said. “I personally don’t think it’s the state’s responsibility to fund this permanently but I think it’s the state’s responsibility to help grow and harbor these partnerships and relationships.”

But the administrative burden – along with the near-constant work convincing politicians to fund it and introducing it to potential partners – often takes Green and Dyer away from the job.

“The downfall of that is there’s only so many people doing the work,” Green said.

This week, Green and Dyer talked with AARP Indiana to discuss how mobile integrated health can help the organization’s members age at home – something the majority of Hoosiers want, AARP said.

Green noted that they, through their statehouse connections, could help find a more sustainable way to support their unit, which isn’t eligible for reimbursement from programs like Medicaid and Medicare.

“Mobile integrated health, like we are seeing in Monticello, is a model for how communities, especially rural ones, can increase access to health care and help older residents stay in their homes and communities,” said Ambre Marr, the AARP Indiana legislative director, in a statement.

“The needs are going to be different depending on the location, but what we have seen is that when these programs are led by trusted entities such as fire departments and community paramedics, they are successful. The key to these programs continuing and growing is finding options for sustainable funding.”

But for the Barnes, Green’s consistent presence is a must – even if it’s just a phone call to alleviate some anxiety. 

“It’s not just a job; he has a heart for older people and seeing that they get the help they need,” Jean Barnes said. “He checked to see how I get from the laundry room down the steps to the garage. We took up some floor coverings and so forth to make it safer for Skip.”

Meeting earlier this week before an AARP film segment, Green and the Barnes shared news of local graduation ceremonies and video of Green’s two-year-old daughter swimming on Memorial Day weekend. To them, Green is family.

“I feel today probably as good as I ever do. I’ve got other issues… a lot of it because of my age, I’m sure. But I am very fortunate,” said Skip Barnes, who intends to live to 100. “If it wasn’t for a lot of people – the nurse at several hospitals, (Green) and, of course, my wife – I wouldn’t be here. 

“I know that and my undertaker knows that too,” he said with a laugh.