The community heart failure program: A trauma-informed heart failure management strategy

BACKGROUND: Individuals with heart failure (HF) and adverse social determinants of health (SDOH) experience significant health care disparities. 

LOCAL PROBLEM: We noted high rates of acute care utilization by patients with adverse SDOH and unmet social needs. 

METHODS: This pilot quality improvement project used a pre-post design. 

INTERVENTION: A nurse-led, trauma-informed, community-based HF program (CHFP) was developed, providing care at each patient's chosen location (eg, shelter, tent). Guideline-directed medical therapy was adjusted to achieve patient goals. 

RESULTS: Sixteen patients participated in the CHFP. Reductions were seen in the number of emergency department visits, mean number of hospitalizations, and days hospitalized. The number of patients with ≥1 hospitalization significantly decreased from 12 to 5 (P = .07). Cardiology outpatient encounters significantly increased from 11.19 to 19.38 (P = .02). 

CONCLUSIONS: CHFP reduced acute care utilization and has the potential to improve patient outcomes.