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

Conditions

• Congestive Heart Failure
• Heart Failure

Eligibility Criteria

Sex

ALL

Age

18 Years - N/A

Healthy Volunteers

Not accepted

Interventions

• Interviews and group discussion for patients and caregivers — OTHER
  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.
• Interviews and group discussion for community health worker and care-team stakeholders — OTHER
  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.

Study Details

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).

Key Dates

First listed

Jul 28, 2026

Start date

Jul 6, 2026

Status verified

Jul 2026

Primary completion

Jul 31, 2028

Completion

Jul 31, 2029

Study Design

Enrollment

75 participants (estimated)

Arms

• Arm: 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
• Arm: Caregivers or family members of eligible congestive heart failure (CHF) patients
  Caregivers or family members of eligible CHF patients nominated by the patient
• Arm: Community health workers and care-team stakeholders
  Community health workers, chronic disease RN care coordinators, education specialists, clinicians, and operational leaders

Primary Outcome Measure

Identification of prioritized barriers to self-care [ Time Frame: Through study completion, an average of 2 years ]

Central Contacts

• Amber Woltzen
  507-422-6732
  [email protected]

Locations (1)

Find similar trials in Rochester, MN

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