Leadership in Integrated Healthcare, Distinguished Service
Montgomery County, Indiana Project Swaddle: In 2013, a small group of committed citizens and public servants in Montgomery County, Indiana recognized novel approaches were necessary to address the health challenges facing the local community. Like many rural communities, its residents are primarily White, Non-Hispanic individuals (92%) who speak English (95%), have a high school degree but somewhat limited college experience (89% high school degree; 18% college degree), have an average annual household income ($53,075), and were born in the US (97%). Montgomery County faces a set of challenges, which are shared by many other rural communities. High teen birth rates, substantial food insecurity, substance use during pregnancy, and limited access to obstetrics care contribute to poor health and well-being of children in Montgomery County. Additionally, poor mental health, limited access to mental and physical health care, high rates of substance use, and a range of factors influencing maternal health are key challenges to the health and well-being of the general community.
In an effort to combat these issues, this coalition focused on developing sustainable, effective prevention and intervention strategies addressing the socioecological determinants of health. As a result of this coalition’s effort, the Montgomery County Mobile Integrated Healthcare-Community Paramedicine (MIH-CP) program was developed. The MIH-CP program uses trained community paramedics to deliver in-home services to patients under the supervision of a physician. The first MIH-CP initiative, funded by a grant from ISDH, proved to be an efficient and effective method for providing care and managing high-risk patients. During the chronic disease pilot program, there was a 98% reduction in ER and hospital visits among participants. The MIH-CP program was quickly expanded to accept patients with other chronic diseases. Additionally, the coalition also developed Project Swaddle, a community paramedicine program to provide in-home prenatal and postpartum services to women with high risk pregnancies.
The purpose of Project Swaddle is to empower women with the skills and environment needed to raise a healthy infant/child, while maintaining their own physical and mental health. The program currently provides the best available level of prenatal care, along with additional services to prepare women for motherhood. Throughout pregnancy and the 16 weeks following birth, community paramedics make regular in-home visits. During these visits, they and a community health worker partner to address the mother and infant’s clinical, behavioral, and environmental needs. While acting as a physician extender for regular prenatal care, and maternal and infant postpartum care, the community paramedics provide transportation assistance, safe sleep education (DOSE), abusive head trauma prevention education (Period of PURPLE Crying), home safety inspections, health and depression screenings, social service referrals, and guidance on coping tools. The community paramedics also provide a warm referral to partner services, including birthing education with a certified Lamaze instructor, lactation consultation, the Baby & Me Tobacco Free Program, and doula services.
Community paramedics also include psychosocial assessments and interventions in their scope of care for pregnant and postnatal women. Their assessments take into account general statements of patient's feelings about self, degree of satisfaction in interpersonal relationships, clients' in-home relationships, most significant relationship, community activities, work or school relationships, and family cohesion, as well as any protective factors like hobbies, relaxation, leisure and rest distribution, and coping strategies for stress. Interventions, including support from a social worker, are available should the client self-report changes in personality, behavior, mood, feelings of anxiety or nervousness, feelings of depression, or use of medications or other techniques during times of anxiety. Screening for substance abuse or misuse is also critical. Community paramedics note any alcohol or drug use, including types and frequency, habits associated with use, such as sharing needles or driving under the influence, and also other types of potentially harmful substances, including caffeine, secondhand smoke, or poor nutritional quality. Unique to Project Swaddle is the ability to provide Medicated Assisted Treatment (MAT), under the direction of a physician, to pregnant and post-natal women.
Patients enrolled in Project Swaddle also have access to telehealth equipment and monitoring (e.g., blood pressure monitoring, body weight assessment, glucose monitoring, physical activity tracking). In the event of an emergency, such as critically high blood pressure, the community paramedic receives automatic notification. If available, they are dispatched to the scene, where they evaluate and care for the patient on-site and determine the severity of the situation. In addition to providing telehealth monitoring and crisis response, the community paramedic is available to patients for questions and routine follow-up via secure text messaging and telephone.
Indiana must continue to address numerous challenges to reach its goal of improving mothers’ health and wellbeing, including unique demographic and environmental factors. Overall, a higher percentage of Indiana’s population is living in poverty or with a disability, compared to the overall US population. In contrast, a lower percentage of the population holds a Bachelor’s degree or lives in an urban area. These factors contribute to decreased access to appropriate healthcare, resulting in increased risk for poor maternal and infant health outcomes. Lack of access to obstetric care is another challenge facing Indiana’s women. According to 2018 data released by ISDH, Indiana is home to 86 birthing facilities. However, 35 out of the 92 counties are without a birthing hospital or an obstetrics and gynecology (OBGYN) provider, giving rise to inconsistent access to quality, timely, and specialized women’s healthcare during pregnancy and postpartum periods in those counties. This crisis continues to grow, as hospitals offering obstetric services continue to close their doors. Three hospitals have done so since the fall of 2017. A sustainable alternative to traditional clinic-based healthcare must continue to be developed.
Community paramedicine and Project Swaddle offer one novel approach to address Indiana’s unique challenges. The goal of community paramedicine is to improve access to care and avoid effort duplication. While these services are often used to address access to care issues among older adults or individuals with chronic diseases, Montgomery County, Indiana discovered the principles of their thriving community paramedicine program could be adapted to a population of at-risk pregnant women and mothers. Project Swaddle currently provides the best available level of prenatal care, along with additional services to prepare women for motherhood.
Although formal evaluation of this CPP has not yet been conducted, preliminary evaluation suggest women enrolled in the program have better than expected outcomes, as do their infants, compared to women not enrolled. Since CPPP implementation in Montgomery County, there have been lower NICU rates and length of hospital stays, fewer preterm births, and fewer child protective services removals than previously experienced among similar women in the community. We have conducted several case studies of the mothers enrolled in the program, which show consistent positive health outcomes for mothers and their infants. Additionally, women report improved social connections among friends and family, and increased community support through resources (e.g., connected to free car seat programs) and interpersonal relationships (e.g., relationship with paramedic).
Division Chief Paul Miller began his career on a paid on-call fire department in 1996 near Flint Michigan prior to accepting a full-time position in June of 1999 with the Crawfordsville Fire Department as a firefighter/EMT. In 2014 Chief Miller was appointed to the rank of Division Chief from Lieutenant where he continues to serve. Chief Miller has previously served as an adjunct instructor for Vincennes University & Ivy Technical College and is a regular featured speaker for many state and national conferences in addition to collaboratively constructing one of the most diverse community paramedicine programs in the country with many non-traditional partners.