Mobile Integrated Healthcare Practice

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CHF Readmission Prevention

Date of latest update

September 2014


Fort Worth and 14 suburban cities in north Texas

For More Information Contact

Matt Zavadsky, Director of Healthcare & Community Integration (NEW title!)

Population Served

Patients at risk for a 30-day readmission post CHF discharge 113 patients enrolled to date

The Need

Patient education on ways to manage CHF post-discharge Effective use of cardiologist and PCP for medical management

The Goal

Improve the patient’s experience of care, including outcome Improve population health Reduce the cost of care Educate on ways to better manage medical needs Educate on need for lifestyle change

Medical Oversight

Patient’s assigned primary care physician (delegated practice) EMS medical director in the absence of above

Key Partners

Medical Control Authority (Emergency Physician’s Advisory Board (EPAB)) John Peter Smith Health Network Texas Health Resources HCA – Plaza Medical Center Baylor Scott & White – Fort Worth Tarrant County Mental Health/Mental Retardation Agency United Way Area Agency on Aging Catholic Charities Resource Recovery Council Perrone Pharmacy Tarrant County Homeless Coalition Tarrant County Public Health Day Resource Center


Specially Trained Mobile Healthcare Practitioners (MHPs) and Critical Care Paramedics (CCPs) RN for case management


Outside Referrals – fee for enrollment

Plans for Sustainability

Continued fees for enrollment (hospitals and other referring sources) Move to capitated arrangement for payers (Cigna-HealthSpring, Amerigroup, Silverback Care Management, etc.)

Technology Used

Regular ALS medical equipment Digital scale IStat point of care testing Testing several telemedicine and telemonitoring platforms SharePoint EMR

Program Results

~77% reduction in readmissions for enrolled patients 4.8/5 Likert scale patient experience rating 38% improvement in self-perception of health status (EuroQol scale)

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Mobile Integrated Healthcare Practice

Funded in part by Medtronic Philanthropy.

Produced in cooperation with the RedFlash Group.