Northwestern Medicine Delnor Hospital has introduced a Mobile Integrated Healthcare (MIH) program designed to deliver in-home care for patients with heart failure. The initiative, a collaboration between the Bluhm Cardiovascular Institute and the Southern Fox Valley Emergency Medical Services system, aims to reduce hospital readmissions by providing clinical support, education, and remote monitoring directly to patients in the Geneva area.
“The Mobile Integrated Healthcare program brings cardiovascular care directly to our heart failure patients removing barriers and enabling earlier intervention when issues arise,” said Jane Wilcox, MD, associate chief of cardiology and heart failure specialist at Northwestern Medicine Bluhm Cardiovascular Institute. “This work reflects the strength and collaboration of our interdisciplinary heart failure team and our emergency medicine colleagues, whose commitment makes programs like this possible and improves outcomes for our patients.”
Heart failure is a chronic condition that can lead to frequent hospitalizations if not managed properly. The MIH program provides short-term follow-up care at home after hospitalization, aiming for a smoother transition to outpatient management.
“Within the emergency medical services system, we often see heart failure patients return because managing symptoms at home can be overwhelming without the proper support,” said Parkson Lin, DO, EMS medical director of Southern Fox Valley EMS System based at Northwestern Medicine Delnor Hospital. “Partnering with the heart failure team through the Mobile Integrated Healthcare program is changing that. By bringing coordinated, in-home support to patients, we’re reducing repeat emergency visits and helping patients avoid inpatient hospitalizations.”
The MIH program acts as a bridge between hospital stays and follow-up appointments. Remote monitoring allows clinicians to identify problems early and adjust treatment plans as needed.
“Managing heart failure is challenging and the period after a hospitalization is when patients are most vulnerable,” said Ross VanDorpe, MD, cardiologist and medical director at the Bluhm Cardiovascular Institute at Northwestern Medicine Delnor Hospital. “Even small changes in symptoms can lead to serious setbacks. By providing structure, support and clinical oversight, this program empowers patients to take control of a complex condition with confidence. It’s an important extension of the high‑quality heart failure care we strive to deliver every day.”
Eligible participants are referred by their clinician. Once enrolled in the four-week program, a specially trained paramedic visits three times: within 1–3 days after referral; around two weeks later; then again near week four.
During these visits paramedics check vital signs such as blood pressure and weight; review medications; provide individualized education on self-management; evaluate health status; assess resource needs like transportation help; and communicate updates with other members of each patient’s care team using remote monitoring technology.
“During our home visits, we focus on listening and understanding how the patient is managing their heart failure at home. We also evaluate their current health status and determine if there is a need for any additional resources such as help with transportation to doctor’s appointments,” said Ken Snow, paramedic with the MIH program and Continuing Education Specialist for Southern Fox Valley EMS System. “The goal is to ensure the patient has the necessary education to understand their disease and their doctor’s care plan, as well as having the support they need so that they can have the confidence and the ability to improve their quality of life. Being able to help patients reach those goals is what makes this program so meaningful.”
Geneva resident Paul LoCicero was among those who benefited from this approach: “Two years ago, I accepted that I was going to die – I even received last rites. But the team at Delnor had other plans for me,” he said about his experience before joining MIH as its first enrollee. “Before, I would struggle to breathe then call paramedics...I would be fine [after hospitalization] but then it would happen again.” Now his care team monitors him remotely: “Now they check in on me...help me adjust my medications...and keep an eye on things before they get out of control…It truly feels like having a guardian angel looking out for me.”
Patients may qualify if hospitalized or considered high-risk for readmission due to heart failure—and must live within Delnor’s service area while being able make independent decisions regarding participation.
Emily Jakacki president of Northwestern Medicine Delnor Hospital commented: “This program is a powerful example of how we’re evolving care beyond hospital walls…reinforces Northwestern Medicine’s commitment delivering high‑quality compassionate care within community…a meaningful step forward improving outcomes neighbors living with heart failure.”
Northwestern Medicine operates under parent organization Northwestern Memorial HealthCare (Fact 3), focusing on world-class patient-centered missions involving care delivery research & education (Fact 4). Its president & CEO is Howard B Chrisman (Fact 5). The organization also recognizes humanitarian contributions (Fact 1)—including awards reflecting compassion—and receives national recognition supporting physician well-being & community service (Fact 2). Strategic collaborations advance research & educational efforts (Fact 6).
The MIH initiative holds accreditation from Illinois Department of Public Health.
For more information about Northwestern Medicine's cardiovascular services visit nm.org/heart or call 312.NM.HEART (312-664-3278).
