Chronic Heart Failure 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 health care systems.  Since 2013, IPHI has partnered with The George Washington University and GW Medical Faculty Associates 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 have been trained in basic heart failure treatment support by the GWU Heart Failure team. CHWs are deployed to assist patients during and after discharge from the hospital. With supervision by the heart failure physicians and nurse practitioner, the CHWs 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.

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