Care Transitions Project

A partnership to improve care transitions and health outcomes for patients with chronic heart failure

Reducing avoidable hospital readmissions is an opportunity to improve quality, increase patient satisfaction, and reduce costs within our health care system. We launched a CHW pilot project with The George Washington University to improve care continuity and coordination, and to reduce hospital readmissions for patients with chronic heart failure.

We are responsible for administering the CHW portion of this project, which focuses on evidence-based strategies that emphasize coordination and continuity of care, prevention and avoidance of complications, and close clinical treatment and management.

Our Responsibilities:

  • Hiring & placing the CHWs;
  • Supporting the training of CHWs;
  • Training the staff at GW Hospital and Medical Faculty Associates on effectively integrating CHWs into the team;
  • Collaborating to ensure effective program model design; and
  • Supporting the evaluation of this pilot project.

Two CHWs hired by us will be trained in basic heart failure treatment by the GWU Heart Failure team. CHWs will be deployed to support patients at patient discharge from the hospital. With supervision by the heart failure physicians and nurse practitioner, the CHWs will work with the patients enrolled in this project to engage them in their homes to:

  • Improve understanding of heart failure medications;
  • Enhance diets that are conducive to improved health;
  • Improve heart failure self-management skills;
  • Provide resources to address social needs; and
  • Improve communication with and utilization of outpatient medical facilities.

This project is funded by The George Washington University Hospital.

If you represent a hospital that is interested in developing a similar program to ensure effective health care utilization, control costs, and improve health outcomes for your patients, we welcome speaking with you. Please contact 202-747-4120, or