Dignity Health and East Valley Fire Departments Partner to Provide Heart Failure Patients with Specialized Care to Prevent Emergency Room Readmissions

Nov. 29, 2016

Patients with heart failure may benefit from a new pilot program now offered at Dignity Health’s East Valley hospitals. The new initiative, led by the City of Mesa Fire and Medical Department, and Dignity Health, aims to improve the rate of emergency room readmissions for patients with heart failure.

Patients with heart failure, who are discharged from the hospital and have gone home, will often return to the hospital’s emergency room because they did not have necessary resources in place at home. Discharge instructions can be complicated and overwhelming, or sometimes plans simply fall through, leading patients back to the hospital for help.

Called a “community medicine program,” the unique group is made up of mobile paramedics, nurse practitioners and physician assistants. Thanks to a $12.5-million grant awarded to the Mesa Fire Department by the Centers for Medicare and Medicaid Services, heart failure patients seen at Dignity Health Chandler Regional Medical Center or Mercy Gilbert Medical Center will be evaluated for the free follow-up program.

“Our goal with this program is really to make sure these patients are ‘back on track’ after being hospitalized,” says Bruce Bethancourt, MD, chief medical officer for the Dignity Health Medical Group.

Heart failure patients qualify for this unique program by residing in participating areas—Mesa, Queen Creek, Gold Canyon and Apache Junction. Patients will be screened and visited by a specially-trained professional who is part of their community medicine program to schedule the in-home visit prior to discharge. The goal of the program is that each of these patients will be visited within 24 to 48 hours of leaving the hospital.

“We know people do not like strangers coming into their home. However, they will allow the fire department to come in, because they are seen as ‘lifesavers,’” adds Dr. Bethancourt .

During the in-home visits, the community medical team will help the patients settle in by starting with a medical assessment. Together, the patient and team member will review medical records and safe use of medications, discuss immunizations and falls prevention, and work to coordinate any needed outpatient care. The team can also assist in making doctors’ appointments and writing necessary prescriptions as well as providing home safety inspections. In addition to medical intervention, Crisis Preparation and Recovery, Inc. will be utilized for patients with behavioral health needs.

“We are proud to partner with the Mesa, Superstition and Queen Creek Fire Departments to provide this service to a population of patients in great need,” explains Dr. Bethancourt . “These in-home visits are efficient because they allow us to catch and address medical issues promptly, reducing the duplication of efforts between emergency rooms and primary care physicians, and reducing readmission to the ER for our high-risk heart failure patients.”