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Navigator Program: Nurse-Led Heart Failure Care Transition Intervention for African-Americans

Cheryl R. Dennison

Cheryl R. Dennison
Principal Investigator

Heart failure is a major public health problem that affects more than 5 million Americans and costs $33.2 billion annually. Heart failure morbidity is reaching epidemic proportions, and African-Americans are disproportionately affected.

Heart failure patients require care from providers in multiple distinct care settings (i.e., hospital, outpatient, home). Therefore, they are at risk for fragmented care which can result in conflicting recommendations regarding self management, confusing medication regimens with high potential for error and duplication, inadequate follow-up, and inadequate patient and caregiver preparation to coordinate care among all healthcare settings.

This study will introduce the community health navigator role, with the goal of identifying and eliminating barriers to heart failure care and improving self-management and outcomes for African-Americans.

Meet the Investigators


Intervention Refinement Phase, months 1-2:
Refine a Heart Failure Care Transition Intervention (HFCTI) to be delivered by RN-CHN team integrating elements of medication and symptom self management, daily monitoring of HF symptoms via HF-HAT telemonitoring system, HF care follow up, and a personal HF care record through inpatient and outpatient provider stakeholder assessments. The HFCTI intervention protocol and training materials, including a case based HFCTI training manual for RN and CHN interventionists, will be finalized. Acceptance and attitudes regarding the HAT system will be assessed in a convenience sample of 10-20 adult heart failure outpatients using attitudinal surveys and structured qualitative interviews.

Intervention Testing Phase, months 3-24:
Test the HFCTI in a sample of African American patients admitted to the hospital for treatment of heart failure. Study participants will be randomly assigned to receive either 1) usual care by their usual source of HF care (N=62) or 2) the RN-CHN team + HF-HAT telemonitoring system intervention for 3 months in collaboration with the participant’s usual source of HF care (N=62). A total of 124 participants will be recruited and randomized (62 in each group). Baseline data will be collected during index hospitalization; outcome data will be collected from existing medical records at JHH and from questionnaires at 30, 90, and 180 days after discharge from index hospitalization. An economic and cost-effectiveness evaluation will be performed by comparing the relative cost and outcome of the HFCTI to the usual care intervention.


McEntee ML, Cuomo LR, Dennison CR. (2009). Patient, Provider, and System Level Barriers to Heart Failure Care. Journal of Cardiovascular Nursing, 24(4):290-298.

Dennison CR, Hughes S. (2009). Imperative to improve care transitions for cardiovascular patients. Journal of Cardiovascular Nursing, 24(3):249-251.


McEntee ML, Johnson BJ, Finkelstein J, Dennison CR. (2010). Establishing feasibility of a telemanagement system to facilitate self care among African American heart failure patients. Heart & Lung: The Journal of Acute and Critical Care, In Press.

Johnson B, McEntee M, Samuel L, Rotman S, Kielty A, Russell SD, Dennison CR. (2010). Adequate health literacy is associated with higher heart failure knowledge and self care confidence in hospitalized patients. Heart & Lung: The Journal of Acute and Critical Care, In Press

Finkelstein J, Dennison CR. A Pilot Study of Home Automated Telemanagement (HAT) System in African Americans with Congestive Heart Failure. Accepted for presentation at the 2010 Second International Conference on eHealth, Telemedicine, and Social Medicine (eTELEMED 2010). February 10-16, 2010 - St. Maarten, Netherlands Antilles. IEEES. In Press.

Dennison CR, Finkelstein J. Design and Implementation of Home Automated Telemanagement System for Patients with Congestive Heart Failure. Submitted for presentation at the International Association of Science and Technology for Development Annual Meeting.