A Community Health Worker Centered Transitional Heart Failure Clinic Addressing Social Determinants of Health Hospital Readmissions Reduction Effort

From the 2021 HVPAA National Conference

Alison Koransky (Temple University Hospital, Lewis Katz School of Medicine), Melody Chiang, Dharmini Shah Pandya


The social determinants of health (SDOH) have been shown to be independent predictors for higher rates of heart failure hospital admissions, lower outpatient follow-up, and poorer health outcomes.1-3

One strategy for addressing the SDOH has been the involvement of community health workers (CHW), trained community members who provide patients with social support and assist in the navigation and coordination of care, which has previously shown promising results in decreasing hospitalization rates and average lengths of stay for patients with chronic illnesses.4-7


We sought to implement a pilot CHW-centered transitional heart failure clinic with the goals of:

  1. Identifying and addressing SDOH needs for our patient population through longitudinal CHW involvement in care coordination
  2. Demonstrate decreased emergency department visits and hospital readmissions after participation


A pilot transitional heart failure clinic was opened at an urban academic center. Our center started by having the CHW team identify patients from the working DRG (drug related group) based on provider documentation and list of high utilizers provided by the insurance companies. Patients were evaluated for the presence of housing, food, utilities, financial, transportation, understanding healthcare, and safety needs through a screening questionnaire. CHWs developed longitudinal relationships with patients through visits during hospital stays, presence at clinic appointments, and check-in calls. Patients were offered transportation to and from clinic appointments, parcels of fresh food, health education, and access to social work services at clinic visits. To evaluate the impact of the clinic, 30-day pre and post enrollment all-cause emergency department visits, readmissions, and clinic show rates were tracked for each patient.


From 6/11/20- 2/21/21, 93 eligible patients elected to participate and attended at least one clinic appointment. The top 3 needs identified on the questionnaire were understanding healthcare (35.8%), transportation barriers (19.4%), and food insecurity (16.4%). Average monthly all-cause emergency department visits for the clinic participant group decreased 41%. The average monthly hospital admissions decreased 21.1%. Average monthly outpatient care visits increased from 82.6 to 196.3 (a 138% increase). The clinic show rate was 77.9%, compared to 50-60%, the average show rate at our institution. Through clinic participation: 5 patients have appointments for ICD placement, 3 patients have been referred for bariatric surgery, and 1 patient is scheduled to receive a mitral clip.


A significant portion of patients admitted for heart failure in our institution were found to identify SDOH needs on a screening questionnaire, with the top needs being: understanding healthcare, transportation, and food insecurity. A CHW driven transitional heart failure clinic that worked to address these SDOH needs through interventions like the provision of transportation, fresh food, patient health education, and social worker access was implemented. Patients enrolled in this clinic exhibited higher than average clinic show rates and decreased 30-day all-cause ED visits and readmissions after participation.

Clinical Impact

Patients enrolled in a CHW driven clinic exhibited reductions in average monthly all cause ED visits and hospital readmissions. In the future, this can be applied to an expanded patient population to further evaluate the impact.

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