Community-Informed Interventions for Equitable Congestive Heart Failure Management in Primary Care
Mayo Clinic
Summary
The purpose of this study is to expand subject matter expertise and sustained capacity for equity-oriented care within the Advanced Care Ecosystem (ACE) by engaging patients, caregivers, community health workers (CHW), and care-team stakeholders in development work focused on adults living with congestive heart failure (CHF) and adverse social determinants of health (SDoH).
Eligibility
- Age range
- 18+ years
- Sex
- All
- Healthy volunteers
- No
Inclusion Criteria: Patients living with congestive heart failure (CHF): * Age 18 years or older. * Diagnosis or clinical documentation of CHF or heart failure in the Mayo Clinic medical record. * Empaneled in Mayo Clinic, Rochester, primary care * Evidence in the EHR of one or more adverse SDoH, elevated utilization, medical/social complexity. * Able to provide informed consent. * Able to participate in study procedures. Caregivers: * Age 18 years or older. * Caregiver with relevant lived, caregiving, or community experience related to CHF, and nominated by the patient. * Able to provide…
Interventions
- OtherInterviews and group discussion for patients and caregivers
Participants will be asked to complete an individual interview or participate in a group discussion lasting approximately 60 to 120 minutes, conducted in person, by telephone, or by Mayo-approved video platform. Interview and discussion guides will include discussion of barriers, facilitators, preferences, priorities, and care gaps related to congestive heart failure self-care, access, transitions of care, community health worker support, caregiver support, social needs, health literacy, language access, trust, and culturally responsive care.
- OtherInterviews and group discussion for community health worker and care-team stakeholders
Participants will be asked to complete an individual interview or participate in a group discussion lasting approximately 60 to 120 minutes. Interview and discussion guides will focus on development of a community health worker competency-based training module and development of workflows for community health workers to support congestive heart failure patients' self-management and care transitions. Participants will provide feedback on implementation barriers and facilitators, including training burden, role clarity, sustainability, cultural responsiveness, and integration with clinical care teams.
Location
- Mayo ClinicRochester, Minnesota