Bridging the Care Gap: Mobile Integrated Health at GRH

Mobile Integrated Health (MIH) is an acute clinical service designed to bridge care gaps identified by a patient's care team through direct home evaluations and interventions. Greater Regional Health launched our MIH program in 2025 to effectively tackle these deficiencies. The MIH program at GRH is dedicated to stabilizing high-risk patients post-discharge, preventing unnecessary emergency department visits, and supporting established care plans with precision.

What is Mobile Integrated Health at Greater Regional Health?

Mobile Integrated Health (MIH) is healthcare centered on patients and based on teamwork, designed to extend care beyond the usual emergency response. Instead of waiting for crises, MIH delivers healthcare directly within the community, emphasizing prevention, chronic disease management, and enhanced access to essential services. By coordinating with teams of healthcare professionals—lead by community paramedics—the program ensures continuous care and a more comprehensive approach to each patient’s needs.

Through home visits, wellness checks, and ongoing health support, community paramedics assist in managing chronic conditions, provide education, and connect patients with additional resources. Serving as a link between individuals and the broader healthcare system, these professionals enhance communication, close care gaps, and promote improved long-term outcomes.

By reaching patients where they are, MIH helps decrease unnecessary emergency room visits, reduces hospital readmission rates, and fosters a more accessible and proactive healthcare experience for the community.

Mobile Integrated Health referrals are ideally suited for high-risk discharges, frequent healthcare utilizers, early-symptom relapsers, and patients with suspected care gaps, such as medication issues or home safety concerns.

The comprehensive scope of MIH services includes clinical support, medication safety, post-discharge stabilization, environment and functional assessments, and care coordination. These services are designed to protect discharge plans, prevent readmissions, and maintain patient stability at home.

Mobile Integrated Health in action:

The concept of Mobile Integrated Health can be best understood through the following example:

A patient with severe COPD was experiencing a predictable cycle of decline. ED visits,

multiple admissions and symptom relapse within days of each discharge. MIH identified the

patient’s specific “relapse window,” corrected medication errors and inhaler technique,

addressed cost-related nonadherence, intervened early in the home during symptom

escalation and coordinated closely with pharmacy and the patient’s providers.

Outcome:

Over the next 60+ days, the patient had 0 ED visits, 0 admissions, regained

medication stability, and re-engaged successfully with outpatient care. All from ~6.5 hours of MIH time. This case highlights how MIH improves patient outcomes, increases system

efficiency, and delivers dynamic, targeted solutions through a mobile clinical model.

Want to learn more about Mobile Integrated Health at GRH? Click here to watch the GRH Podcast with Sam Magill, the Director of Mobile Integrated Health Services or reach out to Sam via email samma@greaterregional.org.