A2 · Post-acute transitional care
Heart failure post-discharge home visits, coordinated from the hospital
Schedule a 72-hour CHF community paramedicine visit before the patient leaves the building, track weight and diuretic adherence, and prove the cohort effect.
Mission template A2 · Heart failure 72-hour
On scene- Received09:12
Referral raised by hospital cm, CHF discharge.
- Scheduled10:04
A program covering the address accepts inside the window: ≤72 hours, then day 7 and day 14.
- En route13:06
Crew departs; the patient receives an arrival window by SMS.
- On scene14:11
Weight; Edema check; Dyspnea scale.
- Completed14:40
Outcome fields recorded (Weight delta; NYHA class); referrer notified.
Why this program
Heart failure decompensation is visible days before it becomes an admission: weight climbing, shoes not fitting, diuretic doses skipped or doubled.
Transitional care assumes somebody sees the patient early. In rural counties the community paramedic is often the only clinician who can be there that fast.
The template is fixed so every referral arrives the same way: a defined trigger, a defined window, a defined skill set, and a defined set of outcome fields. That is what makes the work reportable later without asking crews to write anything twice.
Mission template A2
Heart failure 72-hour · sponsor persona: Hospital CM · window: ≤72 hours, then day 7 and day 14 · single mission · tele-MD optional
Trigger and window
CHF discharge
Window: ≤72 hours, then day 7 and day 14
Skills required: CP
Steps
- Weight
- Edema check
- Dyspnea scale
- Daily-weight teaching
- Diuretic titration per protocol
- Scale provided
Outcome fields
- Weight delta
- NYHA class
- Diuretic adjusted Y/N
- Scale in home Y/N
Escalation and child orders
Weight gain >2 lb/day or >5 lb/week, or SpO₂ <90% → tele-MD
Child orders: Scale, Home health, Pharmacy. Logistics requests are raised on VectorCare and tracked against the same mission.
What the sponsor sees
Transitions-of-care staff see the visit scheduled before the patient is out the door, and the weight trend when it closes.
Status moves through received, scheduled, active, and completed, escalated or aborted. Exception statuses notify the referrer rather than waiting to be discovered at the end of the week.
What the program does
The program accepts, schedules, documents in its ePCR, and records the four outcome fields the sponsor needs.
Programs choose which templates they accept, and set their own coverage area and capacity. Nothing is auto-assigned.
What you can measure
- Share of CHF discharges with a visit inside 72 hours
- Tele-MD consult rate and disposition split
- 30-day heart failure readmission, touched versus untouched
- ED contact within 7 days of the visit
Figures shown elsewhere on this site are illustrative unless a source is given. Your reporting reflects your own missions.
Rural Health Transformation
This template maps to CMS strategic goals 1 and 4. Missions, outcome fields and county-level coverage export for state reporting.
DispatchCare is a technology vendor. It does not administer Rural Health Transformation funds.
Questions buyers ask
CHF discharge. DispatchCare does not receive 911 calls; emergency requests stay in the dispatch system.
Related mission templates
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