Community-Informed Approaches to Enhance Equitable Care for Adults with Congestive Heart Failure in Primary Care

What this Trial Is About

This research aims to improve equitable care for adults living with congestive heart failure CHF by engaging patients, caregivers, community health workers, and care-team members. The study focuses on addressing adverse social determinants of health SDoH and medical or social complexity among adults receiving primary care. It seeks to expand expertise and capacity within the Advanced Care Ecosystem ACE to better support CHF management in primary care settings. Participants include adults with CHF and adverse SDoH, their caregivers or family members nominated by patients, and community health workers or care-team stakeholders involved in CHF care and related support roles. The study involves interviews and group discussions lasting 60 to 120 minutes, conducted in person, by telephone, or video. Patients and caregivers discuss barriers and priorities related to CHF self-care, care transitions, and culturally responsive support. Care-team members provide feedback on training, workflows, and implementation challenges for community health worker support. Throughout the study, researchers will identify key barriers to self-care among participants over an average period of two years. Participants provide informed consent and engage in discussions exploring various aspects of CHF care, social needs, health literacy, and access issues. The study involves ongoing collection of insights to inform development of equitable care strategies and community health worker training. Participation includes assessments of care gaps and preferences, helping to shape better community and clinical support for CHF management.

Community-Informed Interventions for Equitable Congestive Heart Failure Management in Primary Care