Overview
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
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.
