Community-Informed Interventions for Equitable Congestive Heart Failure Management in Primary Care

Inclusion Criteria:

Patients living with congestive heart failure (CHF):

* Age 18 years or older.
* Diagnosis or clinical documentation of CHF or heart failure in the Mayo Clinic medical record.
* Empaneled in Mayo Clinic, Rochester, primary care
* Evidence in the EHR of one or more adverse SDoH, elevated utilization, medical/social complexity.
* Able to provide informed consent.
* Able to participate in study procedures.

Caregivers:

* Age 18 years or older.
* Caregiver with relevant lived, caregiving, or community experience related to CHF, and nominated by the patient.
* Able to provide informed consent
* Able to participate in study procedures.

Community health worker and care-team stakeholders:

* Age 18 years or older.
* Current or recent role relevant to CHF care, transitions of care, SDoH, patient education, or CHW workflows.
* Able to provide informed consent
* Able to participate in study procedures.

Exclusion Criteria:

* Under age 18 years.
* Unable or unwilling to provide informed consent.