The Delta Heart Health Network is a rural health initiative developed to implement and evaluate the impact of a new cardiovascular health program in the heart of the MS Delta. This initiative is a collaborative program between rural hospitals and our network of community health workers. It emphasizes care transitions with a focus on cardiovascular health.
The project establishes a series of coordinated, systematic activities designed to improve patients’ cardiovascular health by improving care coordination and post hospital discharge care throughout the service area.
The first set of activities involves working directly with the hospital administration to target those patients
in need of additional assistance post-discharge.
The second set of activities involves health education, screenings, obesity prevention programs, and local outreach by a network of Community Health Workers, who will work with area churches, work sites, grocery stores, community gardens and other public settings to improve access to services.
- Establish a network of Community Health Workers (CHW) to increase care transitions and coordination of services between service providers;
- Raise awareness and increase adoption of healthy lifestyles through CHWs, with emphasis on rural and impoverished neighborhoods;
- Improve care coordination and awareness among healthcare providers regarding their patients’ health status.
- Reduced 30-day unplanned readmissions
- Enhanced chronic disease management
- Increase in the number of patients with heart disease receiving nutrition counseling and education
- Decreased smoking rate through education
- Increased awareness of the early warning signs for heart attacks
- Increased awareness of heart disease as well as its signs and symptoms
How to Enroll:
Patients hospitalized with heart-related diseases and other chronic conditions in one of the Delta Heart Health Network’s five partner facilities are identified and offered enrollment in the program. From there, DHA community health workers stay in contact with patients over a 45-day period starting the day of discharge.