AHN Cardiovascular Institute at Allegheny General Hospital Launches Pilot Study Benefitting Heart Health in Pittsburgh’s North Side Community

The “Heart-to-Heart” Program Offers Eligible North Side Residents Take-Home Kits to Self-Monitor Blood Pressure and Heart Rate, Aiming to Improve Overall Health and Reduce Hospital Readmissions

PITTSBURGH – Cardiologists at Allegheny Health Network (AHN) have announced the launch of an innovative pilot program that improves access to community-based resources and offers at-home monitoring tools to better care for North Side residents diagnosed with severe hypertension or heart failure.

“The Northside Heart to Heart Project” is based out of AHN’s flagship academic medical center, Allegheny General Hospital (AGH), and is under the direction of Anita Radhakrishnan, MD, FACC, cardiologist and diversity, equity and inclusion officer at AHN’s Cardiovascular Institute (CVI).

The goals of the pilot, in addition to better managing hypertension and heart failure symptoms, are to improve the patients’ overall well-being and reduce hospital readmission rates.

“Patients ultimately have improved long-term outcomes when they have a clear understanding of their diagnosis, have the resources to monitor their vital signs at home, and feel empowered to make the necessary lifestyle and medication adjustments that result in better heart health,” said Dr. Radhakrishnan. “This pilot program allows our clinical team to better identify, equip and support our most complex cardiac cases, right in their very own community. It’s an exciting effort that I’m sure will make a significant difference in the lives of so many residents throughout the North Side.”

Pittsburgh’s North Side was chosen for the pilot because of its proximity to AGH, which is also based in the North Side, and because of the neighborhood’s demographic characteristics. More than 1 in 5 North Side residents live below the poverty line, and life expectancy in some North Side neighborhoods is a full 10 years below the national average because of the many socio-economic barriers and other health care access issues faced by its residents.

Place-based programs like these are meant to tackle these disparities. Eligible patients for the “Heart to Heart” pilot program are diagnosed with hypertension or heart failure and reside within select ZIP codes covering Pittsburgh’s North Side community. The program’s designated nurse coordinator, Carlotta Burgess RN, BSN, supplies patients with heart care kits, free of cost, packed with a digital blood pressure machine, a weighing digital scale, a watch fitness heart rate monitor, a medication box and heart-healthy recipe books. Based on individual needs, Burgess will also refer patients to programs like Thrive 18.

“Thrive 18 connects the most vulnerable people with integrated support systems of community resources and community health workers using a strong centralized wellness approach,” continued Dr. Radhakrishnan. “They are an integral component of the ‘Heart to Heart’ program, as a significant majority of participating patients screen positive for barriers including access to healthy food, transportation, housing, and financial instability, all which directly impact a person’s overall health and wellbeing.”

In addition to Thrive 18, the program has partnered with teams throughout the Network to combat common barriers to healthy living. The “Heart to Heart” nurse coordinator can work closely with those eligible to refer and guide them to the AHN Healthy Food Center, pharmacy discount programs, tobacco cessation programs, Healthcare@Home and more.

An important element of the “Heart to Heart” program is consistent communication between the patient and nurse coordinator. On a weekly basis, Burgess calls the patients at a time of their convenience to collect their weight, blood pressure, heart rate, medication adherence/side effects, activity and any cardiac-related symptoms. She then acts as a liaison between the patients and their respective cardiologists, allowing for eased access to care management if anything abnormal is detected.

“The weekly touchpoints between our team and the patient are invaluable because they create an accountability that results in better long-term outcomes and overall engagement,” said Craig Alpert, MD, cardiologist and member of the program’s leadership team. “If we can empower our patients to be more active participants in their health with useful tools and resources, we’re confident that reductions in blood pressure, weight and other heart-related symptoms will follow.”

In 2021, AHN physicians admitted 1,130 North Side residents diagnosed with severe hypertension or heart failure to AGH. The “Heart to Heart” pilot project was supported by Highmark Foundation and Boston Scientific and has enrolled 120 patients to date with the goal of 500 over the next three years. Reported outcomes, measured by readmissions and general quality of life scores, are expected at the one- and three-year mark.

For more information on the Heart-to-Heart program, please contact anita.radhakrishnan@ahn.org, and for more information on the AHN Cardiovascular Institute, go to ahn.org

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