Transitional Health Support

The Client

Baltimore Mobile Integrated Health logo

Baltimore Mobile Integrated Health (MIH) 

The Baltimore City Fire Department (BCFD), University of Maryland Medical Center, the City of Baltimore, and University of Maryland, Baltimore have partnered to launch a new healthcare delivery model for selected areas of Baltimore City. This innovative community-based program will support the health of individuals through a comprehensive, free, multidisciplinary care model for patients, which provides care outside the hospital setting and is designed to reduce health disparities, decrease emergency department visits, and prevent hospital readmissions.

Mobile Integrated Health’s (MIH) Transitional Health Support (THS) is designed to help patients with multiple social, environmental, and healthcare challenges to improve the successful transition from hospital to home. The THS multidisciplinary team is comprised of community paramedics (CP), nurses (RN), community health workers (CHW), emergency medical technicians (EMT), social workers, pharmacists, nurse practitioners (NP), and physicians (MD). This team uses a holistic, evidence-based, and modern approach to provide robust, patient- centered support to individuals and their families at home, after discharge from hospital.

The Problem

The goal of the project was to identify relevant metrics to collect that could be used to conduct analyses that support the optimization of key scheduling and enrollment decisions in a way that improves operational and patient outcomes. 

For scheduling, key questions were:

  • How often should THS providers see patients over a 30-day period and at what interval?
  • What is the impact of expanding THS program operations from five to seven days versus going to 10-hour days?
  • What THS field team schedule maximizes patient contact?

For enrollment, key questions were:

  • What THS enrollment strategies are optimal?
  • How can the THS operations current operational construct be optimized?
  • What resources are required to expand the program to an additional zip code (21215)?
A hispanic doctor speaks to an African American man about his health.

The Approach

Through an assessment with core THS staff, the team uncovered numerous operational pain points within the program. Key metrics were identified to be monitored on a regular basis to help drive optimal decisions around program operations.

The Solution

The Pro Bono Analytics team recommended that THS should create optimized reporting capabilities to begin actively monitoring key metrics.

 Next steps were identified as follows:

  • Begin collecting metrics in a single system on a daily basis
  • Optimize reporting capabilities by creating integrated data sources and building reports/dashboards to monitor KPIs (This included the suggestion/detailing of a scheduling dashboard, an enrollment dashboard, and a general patient reporting dashboard)
  • Conduct critical data analysis to answer operational questions

Project at a Glance




Baltimore, MD

Completed in


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