Nurse Practitioner Supervised Integration of Community Health Workers in Home Based Heart Failure Care

Abstract

Background Community health workers (CHW) are proving to be beneficial in chronic care disease model. Not much has been reported on integrating CHW in chronic HF care and their effect in improving quality of care. We piloted a program involving integration and supervision of CHW in home based HF care by heart failure nurse practitioner (HFNP) in a minority underserved population. Methods We trained and deployed CHWs to assist HF patients after hospital discharge. In addition to basic CHW education, CHWs received intensive HF training by our HF NP and MDs. CHWs utilized a checklist of medical and social items to address at each contact and were in contact with the HF NP for clinical decision making. CHWs provided a total of #1108 services including 1) review labs, 2) medication education, 3) heart failure education, 4) reinforce sodium and fluid intake, 5) diet education, 6) medication adjustment, 7) medication set‐up, 8) medication refill, 9) review discharge plan, 10) schedule appointment, 11) referral to provider, 12) urgent triage, 13) social service referrals, 14) pharmacy prescription drop‐off, 15) deliver medication, 16) link insurance, and 17) family education. Results Over 8 months 2 CHWs served 62 patients (22 Medicaid, 24 Medicare, 16 commercial insurance), mean age 62.7 years, 45% female. There were 651 successful (of 836 attempted) CHW- patient contacts (home visits/phone calls). 8.1% patients had Conclusions NP trained and supervised CHWs with specialized HF training, use of a structured visit checklist, and integration with a HF medical team provide comprehensive home based HF care resulting in low 30 day rehospitalization. Future studies should address cost effectiveness of this approach and healthcare provider burden.