July 30, 2025
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Trinity Health Mid-Atlantic has developed a new program that provides individualized care plans to patients with heart failure. The goal is to address structural barriers that contribute to worse outcomes among low-income and minority populations.
Heart disease is the leading cause of death in the United States, and people in Philadelphia die of it at higher rates than elsewhere in Pennsylvania. Additionally, Black, Hispanic, Asian and Native American people are at higher risk than white people.
Disparities in the rates and outcomes for cardiovascular disease are "one of the starkest reminders of social injustices, and racial inequities, that continue to plague our society," a 2022 paper in the American Heart Association journals states.
"(Heart failure) disproportionately affects low-income and minority populations, and a lot of this is because of social determinants of health," said Dr. Cheryl Jackson, an internal medicine physician at Trinity Health Mid-Atlantic, which operates Nazareth Hospital in Northeast Philadelphia, Mercy Fitzgerald Hospital in Darby and St. Mary Medical Center in Langhorne, among other health care facilities.
Structural barriers that have played a part in creating these disparities include access to medical insurance and quality health care, health education and literacy, housing and economic stability.
To help address these social determinants of health and improve outcomes in cardiovascular disease, Jackson has created a program that provides wraparound services to patients experiencing heart failure and their families.
The "HF-PUMPED" program includes social workers, community health workers, pharmacists, nurse managers and physicians who develop individualized treatment plans for patients with heart failure.
Heart failure is a type of cardiovascular disease that occurs when the heart is not able to pump blood as well as it should throughout the body. As a result, cells do not get the oxygen and nutrients they need.
Some people never have symptoms or do not have symptoms until the disease is advanced. Symptoms may include shortness of breath, fatigue even after resting, coughing while lying down and swelling of the legs, ankles, feet, stomach and neck veins, according to the Mayo Clinic.
Approximately one third of Philadelphia residents have high blood pressure, a major risk factor for heart disease.
"Heart failure doesn't also come in a vacuum," Jackson said. "It's usually also associated with kidney disease, also with high blood pressure and increased risk of so many other co-morbid diseases. And so if we can tackle this, then we think that our patients' health outcomes will be better."
Many medications are available to treat the different types of heart failure. But successful treatment must also involve controlling blood pressure, eating a heart-healthy diet, exercising in moderation, and potentially losing weight, among other factors, according to Johns Hopkins Medicine.
The main goal of the new program is to "support patients, educate them, meet them where they are," Jackson said. Earlier this month, it was one of two programs to receive a 2025 Clinical Care Innovation Grant from Independence Blue Cross.
The HF-PUMPED team will help patients keep track of their appointments, get transportation to and from them, access ways to pay for expensive medications, if needed, and understand paperwork when they are discharged from the hospital – all of which can be overwhelming to patients, Jackson said.
"We really have to have a patient-centric approach where we support and provide wraparound services, because it's not just medical care, it's social care," Jackson said. "It is addressing the influences on health beyond medicine."
