Being hospitalized for four days with a serious heart condition shook Carla Hannaford of Tualatin.

 “When the time came for me to go home, I was truthfully a little scared and concerned,” she confides. When caregivers at Legacy Meridian Park Medical Center offered to connect her with a community paramedic to check on her in her home within the next couple days, Hannaford felt a sense of relief. “I thought it was a great idea,” Hannaford says. “It gave me peace of mind knowing someone would be checking on me with medical knowledge and real information to help me.”

That someone was Tualatin Valley Fire & Rescue firefighter paramedic Stephen Linden.

“The first time I came to see Carla, she was a little weak, fragile,” recalls Linden during his third home visit. “I saw a remarkable difference in her between our first and second visit. She’s stronger and has more energy. It’s great to see her doing so well.”

As part of TVF&R’s mobile integrated health care program, Linden visits Hannaford in her home, where he performs a patient assessment, checks for any medication issues and takes time to go over any concerns Hannaford and her physician might have.

“He has given me so much information about my recovery and took the time to show me how to use my inhaler correctly,” Hannaford says. “During one of our visits, he found an issue, contacted my doctor, and I was seen timely. It meant a lot to me when he told me that I could call him if I had an issue. My son calls him Super Steve.”

Providing mobile integrated health care at no cost to the patient is a priority for Tualatin Valley Fire & Rescue.

“We are already part of the health care system, and mobile integrated health care is another area where our firefighter paramedics can help people in our community,” says Division Chief Mark Stevens, who oversees TVF&R’s program. “Our firefighters are trusted people who go into homes all the time to help people in need. This program is a way we can help people transition from the hospital to their home and sort out any barriers that might prevent them from getting better.”

For the past several years, the district has participated in several pilot projects with local hospitals and agencies to improve outcomes for patients suffering a chronic medical or mental health condition.

One of those pilots evolved into a contract with Legacy Meridian Park Medical Center for mobile health care, where firefighter paramedics visit patients after they are discharged from the hospital, with a goal of decreasing hospital re-admissions. According to recent data, the average hospital stay for patients transported after a 911 emergency call is 3.5 days. At discharge, high-risk patients are identified by the hospital staff and asked to voluntarily participate in the mobile integrated health care program.

 A review of patient data conducted by TVF&R showed patients who opted not to participate in the project had a 23.5 percent readmission rate, while patients who chose to participate in the project had a readmission rate of only 6.3 percent. With the average cost in the United States for a hospital readmission ranging anywhere from $10,000 to $40,000, and hospitals subject to losing Medicare reimbursement for patients readmitted within 30 days of discharge, this project benefits all involved, Stevens says. Ultimately, patients receive better care, they stay out of the hospital, and the 911 emergency dispatch system receives fewer calls.

During home visits, paramedics perform a patient assessment that includes vital signs, blood glucose monitoring, 12-lead EKG (as requested), and medication review. They also review daily weight, blood sugar, and physical activity logs the patient keeps for primary care physicians.

The initial visit also includes an environmental assessment designed to decrease fall risks and create on overall safe living environment. Paramedics record the findings of their visits, and this information is shared with the hospital, case managers and patient’s physician.

TVF&R continues to work on forming new relationships throughout the medical community, including a partnership with Providence St. Vincent Medical Center. These partnerships will advance an effort to decrease 911 usage, emergency room and hospital admissions, and re-admissions. “TVF&R is in the process of expanding our mobile integrated health care program to serve more Medicaid and high-risk patients,” Stevens says. “We want to meet the needs of more patients, improve their access to health care, help them stay out of the hospital, and improve their quality of life.”