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Purpose

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).

Conditions

Eligibility

Eligible Ages
Over 18 Years
Eligible Sex
All
Accepts 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 informed consent - Able to participate in study procedures. Community health worker and care-team stakeholders: - Age 18 years or older. - Current or recent role relevant to CHF care, transitions of care, SDoH, patient education, or CHW workflows. - Able to provide informed consent - Able to participate in study procedures.

Exclusion Criteria

  • Under age 18 years. - Unable or unwilling to provide informed consent.

Study Design

Phase
Study Type
Observational
Observational Model
Other
Time Perspective
Prospective

Arm Groups

ArmDescriptionAssigned Intervention
Adults living with congestive heart failure (CHF) Adults living with CHF receiving primary care at Mayo Clinic Rochester with adverse SDoH, elevated utilization, or related medical/social complexity
  • Other: Interviews 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.
Caregivers or family members of eligible congestive heart failure (CHF) patients Caregivers or family members of eligible CHF patients nominated by the patient
  • Other: Interviews 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.
Community health workers and care-team stakeholders Community health workers, chronic disease RN care coordinators, education specialists, clinicians, and operational leaders
  • Other: Interviews 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.

Recruiting Locations

Mayo Clinic
Rochester, Minnesota 55905
Contact:
Amber Woltzen
507-422-6732
woltzen.amber@mayo.edu

More Details

Status
Recruiting
Sponsor
Mayo Clinic

Study Contact

Amber Woltzen
507-422-6732
woltzen.amber@mayo.edu

Notice

Study information shown on this site is derived from ClinicalTrials.gov (a public registry operated by the National Institutes of Health). The listing of studies provided is not certain to be all studies for which you might be eligible. Furthermore, study eligibility requirements can be difficult to understand and may change over time, so it is wise to speak with your medical care provider and individual research study teams when making decisions related to participation.