PROJECT SUMMARY
Heart disease is the leading cause of death for men, women, and people of most racial groups in the United States, with
over 6 million Americans currently living with congestive heart failure (CHF). Nationally, African American (AA) men
have the highest CHF death rates of all races. AAs have a higher prevalence, a higher 5-year risk of mortality after initial
diagnosis than Caucasians, an increased hospitalization risk, and a 30% increased risk of 1-year mortality if they have two
or more hospitalizations within any year. Prevalence and mortality risk are nearing twice the national average in many
Arkansas counties. Arkansas also has the third highest concentration of CHF death rates of all 50 states. Furthermore, care
delivery systems (i.e., hospitals, and nurses) are struggling to balance the needs of CHF patients against the variability of
unplanned critical care needs in the ongoing, large-scale communicable disease outbreaks. However, the routine,
preventive, and urgent care needs of AAs with CHF can not be deprioritized because of health system inelasticity. If so,
health disparities in AAs will be further exacerbated. Since the "one-size-fits-all" approach to care delivery (i.e., the same
level of resources provided to all patients) is clinically ineffective and wasteful, the efficient allocation of clinical
resources (e.g., nurses) fuels the need for more innovative, evidence-based and nurse-led approaches to stratifying risks
among AA patients. Risk stratification provides a systematic, equity-driven method of assessing and prioritizing patients,
allocating high-intensity resources for patients who need care the most. Yet, the clinical roles that are heavily associated
with decreasing hospitalizations by 84% (i.e., RNs) are found on the care delivery teams of AAs at a rate of 50% less than
that of Caucasian patients with CHF in Arkansas, a dyer health equity problem. Therefore, the primary objective of this
study is to construct a comprehensive sociotechnical framework for risk stratification (i.e., care delivery team composition
model, risk guidelines, and a usable risk index/score for care delivery), supporting equitable care delivery of AAs with
CHF. Our success will (1) reveal how nurses and care delivery teams influence care outcomes and provide evidenced-
based recommendations on composing care delivery teams/models that are associated with decreased hospitalization,
increased days between readmission, and decreased care charges, and (2) advance the role of nursing practice is stratifying
hospitalization risks of African Americans with CHF.
