Mi Puente: My Bridge to Better Cardiometabolic Health and Well-being

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 DESCRIPTION (provided by applicant): Individuals of low socioeconomic (SES) and ethnic minority status, including Hispanics, the largest U.S. ethnic minority group, are disproportionately burdened by chronic cardiovascular and metabolic conditions ("cardiometabolic" e.g., obesity, diabetes, hypertension, heart disease). High levels of unmet behavioral health needs (e.g., related to mental health, life stressors, healthcare access) in this population contribute to the striking disparities in disease prevalence and outcomes. Differences in the quantity and quality of health care targeted to and received by members of the Hispanic population contribute to these disparities. Inequities in health care access and use result from the interaction of several factors, such as those related to low SES, and cultural, language, and/or communication-style differences. Our established academic-healthcare-community partnership has unique experience in developing and testing innovative, cost-effective, and sustainable chronic care interventions to reduce disparities and improve health in underserved communities. The proposed randomized controlled trial will test the effectiveness of Mi Puente ("My Bridge") compared to Usual Care (UC; evidence-based, best practice discharge procedures) in 560 Hispanics adults, hospitalized with 2 or more cardiometabolic conditions and behavioral health concern(s) at a large safety net hospital near the US/Mexico border in San Diego, CA. Mi Puente is an interdisciplinary program that applies a sustainable nurse + volunteer team approach, and builds upon a strong collaborative partnership between inpatient/"referring" and outpatient/"receiving" care settings to improve continuity of care and address the integrated (i.e., physical and behavioral) health needs of at-risk Hispanics. Informed by the Social Ecological Model, Resources and Support for Self-Management Model, and Transtheoretical Model of behavior change, Mi Puente includes in-hospital coaching visit(s) from a Behavioral Health Nurse, and post-discharge supportive telephone calls from the nurse (week 1) and a specially-trained Volunteer Peer Mentor (weeks 1-4) that will assist patients in navigating the multi-level barriers that contribute to inequities in health care access and use, and in turn, perpetuate disparities in cardiometabolic and behavioral health. Electronic medical records (EMR) will be used to identify eligible patients and evaluate re-hospitalizations, our primary outcome, at 30- and 180-days. Changes in patient-reported physical symptoms, quality of life, healthcare utilization, patient activation, and support resources for chronic disease management will be evaluated across six months. Thorough process and cost- effectiveness analyses will evaluate the scalability and sustainability potential of Mi Puente. By capitalizing o existing hospital-based resources, and by addressing critical components of mind and body via an interdisciplinary, culturally-tailored, and sustainable intervention, Mi Puente aims to reduce health disparities in the growing and aging US Hispanic population, and holds promise for impactful expansion to other conditions and underserved populations.