Northwestern Medicine has introduced a Mobile Integrated Healthcare (MIH) program at Delnor Hospital in Geneva, Illinois, aimed at providing proactive, in-home care for patients with heart failure. The initiative is a partnership between the Bluhm Cardiovascular Institute and the Southern Fox Valley Emergency Medical Services system.
The MIH program is designed to reduce hospital readmissions and help patients manage their condition more effectively by delivering clinical support, education, and remote monitoring directly to their homes. Heart failure often leads to frequent hospitalizations if not managed properly. This new approach offers short-term follow-up care after hospitalization, helping patients transition smoothly to outpatient management.
“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.”
Parkson Lin, DO, EMS medical director of Southern Fox Valley EMS System based at Northwestern Medicine Delnor Hospital, added: “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. 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.”
Clinicians monitor enrolled patients remotely to identify issues early between clinic visits. Ross VanDorpe, MD, cardiologist and medical director at the Bluhm Cardiovascular Institute at Northwestern Medicine Delnor Hospital said: “Managing heart failure is challenging and the period after a hospitalization is when patients are most vulnerable. 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.”
Patients eligible for MIH are referred by their clinician following a schedule of three home visits over four weeks: within 1–3 days after referral; around two weeks later; then about four weeks after referral. During these visits paramedics check vital signs such as blood pressure and weight; review medications; provide education on disease management; assess health status; determine resource needs such as transportation assistance; communicate updates with care teams; and use remote monitoring technology for timely interventions.
Ken Snow, paramedic with MIH program and Continuing Education Specialist for Southern Fox Valley EMS System stated: “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. 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 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,” said LoCicero who was first enrolled in MIH program.“Before I would struggle to breathe then call paramedics… Now they check in on me help me adjust my medications… Instead of focusing on winning battle they’re focused on winning war… It truly feels like having guardian angel looking out for me it’s given me whole new life.”
To qualify for MIH participation individuals must live within Northwestern Medicine Delnor Hospital service area be alert able make independent decisions willing participate outpatient care established patient Bluhm Cardiovascular Institute Geneva.
The community-centered approach removes obstacles such as transportation or mobility challenges improving access specialized care especially those not qualifying traditional home health services.
“This program is a powerful example of how we’re evolving care beyond hospital walls making it accessible more patients,” said Emily Jakacki president Northwestern Medicine Delnor Hospital.“This initiative reinforces Northwestern Medicine’s commitment delivering high-quality compassionate care within community.It’s meaningful step forward improving outcomes neighbors living with heart failure.”
The MIH program operates under accreditation from Illinois Department Public Health.
Northwestern Medicine functions under its parent organization Northwestern Memorial HealthCare (https://news.nm.org/). The institution aims for world-class patient-focused healthcare encompassing clinical practice education research while engaging strategic collaborations advance these missions (source). Howard B. Chrisman serves as president CEO (source). Northwestern Medicine also recognizes community contributions through humanitarian awards reflecting compassion impact (source) alongside national recognition supporting physician well-being (source).
For more information about cardiovascular services visit nm.org/heart or call 312.NM.HEART (312-664-3278).
