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.

Often when patients with heart failure are discharged and home, they will 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 medical unit,” the unique group is made up of mobile paramedics, nurse practitioners and physician assistants. Others to join Mesa Fire and Dignity Health in the new community service initiative include the Superstition and Queen Creek fire and medical departments, and an organization called Crisis Preparation and Recovery, Inc.

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

Thanks to a $12.5-million grant from 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. The patients who qualify by residing in participating areas—Mesa and Apache Junction—will be notified about the program and visited prior to discharge by a specially-trained paramedic who is part of their residential area’s fire department team.

Once these patients are home, they will be visited by their designated fire department within 48 hours.

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

During the in-home visits, the community medical unit will help the patients settle in by starting with a medical assessment. Together, the patient and unit member will review medical records and safe use of medications, discuss immunizations and falls prevention, and work to coordinate any needed outpatient care. The unit can also assist in making doctors’ appointments and writing necessary prescriptions as well as providing home safety inspections.

“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,” Bethancourt said. “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 patients.”