This was a qualitative study of participants who received the 30-day digitally enabled CHW intervention in a pilot randomized controlled trial. All participants had a diagnosis of HF listed on their problem list within the electronic medical record, were hospitalized at the time of enrollment, and had been hospitalized at least once in the 12 months prior to enrollment. Participants were initially identified for trial participation through inpatient electronic health records at an academic medical center. Intervention participants were paired with a CHW and the digital platform. The digital platform was connected to a mobile phone app with features including a digital weight scale, a digital blood pressure monitor, a symptom questionnaire, educational videos, and an arm-worn sensor monitoring oxygenation, steps taken daily, and heart rate. The pilot trial details, including procedural flow, inclusion criteria, and study design, are described in a previous publication [19]. Of the 19 participants who completed the intervention, 19 were successfully contacted for qualitative interviews.

All interviews were conducted after the intervention via telephone 31 to 45 days after hospital discharge, and interviews lasted 20 to 45 minutes in length. An interview guide was developed through key informant interviews with patients, HF specialists, qualitative research experts, senior scientists, health services researchers, and primary care physicians. This was coupled with a review of literature associated with prior qualitative HF studies [21]. The guide covered prespecified domains, and consistency was ensured by having all interviews conducted by a senior clinical researcher (NS). None of the researchers or coauthors in this study were involved in direct patient clinical care or the delivery of the trial intervention. Pretesting of the interview guide was performed with 3 participants; no additional modifications were made and the 3 pretesting participants were included in the full sample. The interview guide included 21 items in total, and major domains were barriers and facilitators to managing HF care at home, use of CHW care in HF at home, remote monitoring in HF, and perceptions related to use of technology in HF (Multimedia Appendix 1). All procedures were approved by the Mass General Brigham Institutional Review Board (protocol number 2018P002014) on September 9, 2022, and all participants provided written informed consent.

Transcripts from interviews were analyzed verbatim with the Dedoose (version 8.3.47b) platform. An analytic framework was developed based on the recurring themes that emerged during interviews. To optimize reliability, 2 members of the study team (NS and JC) independently reviewed the data, identified themes, and collaboratively applied the framework to categorize and interpret findings. Weekly meetings occurred for discussions focused on data interpretation and common themes. Content analysis was completed by each coder for each patient interview prior to meeting; this facilitated consensus for all generated codes. Intercoder reliability was achieved and any discrepancies were resolved with a third researcher (KD) with expertise in qualitative research and patient interviews. The available cohort was exhausted and all responses generated by interview participant responses were analyzed. Structured chart reviews were also performed via the electronic health record and stored in a Research Electronic Data Capture (REDCap; Vanderbilt University) database [22]. Data related to demographic information, insurance status, education, and major medical and psychiatric comorbidities were collected in the chart review.

The research team used a formal report generated by the electronic medical record to identify eligible patients. Screening for eligibility was completed by research interns trained to assess eligibility, approach, and enroll participants as a part of standardized research procedures. Participants were not randomized to the intervention or control arm until all standardized study enrollment procedures were complete. Research interns were unaware of the randomization assignments until after all enrollment procedures were complete. In addition, the qualitative interview guide was developed to standardize questions asked of participants, probe any anticipated answers, and accurately capture the participant perspective. The research team was also mindful of the extent to which data can change over time during analysis and tracked all coding decisions meticulously. While the perspectives gathered from participants may not apply to those in other or non-HF populations, the themes may apply to other cohorts with similar characteristics. The small sample size facilitated in-depth and authentic interviews reflective of the patient experience. While the nature of qualitative studies can make replication challenging, the research focus was on gathering individual perspectives to add to the evidence base for HF care at home.

Institutional review board approval was obtained from the Mass General Brigham Human Research Committee on September 9, 2022 (2018P002014). All enrolled participants provided written informed consent prior to this study. Data were anonymized before analysis to ensure confidentiality. All study data reported were deidentified. For remuneration, US $50 was provided to participants at the time of enrollment and an additional US $200 was provided after successful study completion. All methods were carried out in accordance with guidelines and regulations outlined by the Mass General Brigham Institutional Review Board.

One of the most common themes described by participants was how well the intervention worked in terms of helping them manage their HF at home. Several individuals emphasized that the platform and CHW outreach complemented one another by helping reduce anxiety about self- management and facilitate engagement in care. One participant noted the following:

Participants also noted that CHW staff played a key role in making the digital platform more approachable, especially for those unfamiliar with the technology. This was particularly true for those that had not used digital platforms in the past.

Participants reported that the intervention helped them better understand their HF and how their self-care behaviors directly impacted their health. Several individuals described gaining new knowledge about the importance of tracking vital signs, medication adherence, and recognizing early signs of exacerbation. As one participant noted,

Others described how education from the intervention and real-time feedback from the monitoring tools prompted changes in their behavior, including more consistent medication use and routine self-monitoring.

Participants reported that the digital health platform fit easily into their daily routines and supported consistent engagement with self-care activities. Several individuals described the process of using the device as quick and manageable, with one noting,

Others emphasized how the platform helped reinforce new habits for routine monitoring that they had previously struggled to adopt, despite prior clinical advice. A number of participants shared that the consistency of daily use also appeared to support habit formation over time.

Participants described CHW care as a consistent and accessible source of support during the intervention. Participants offered that CHWs assisted with helping clarify their care plans, providing accountability for managing their HF, and supporting use of the digital platform. One participant shared their CHW helped them stay on track through regular check-ins:

A number of participants cited CHW-specific education and health care coaching as an important part of the intervention. Participants also identified CHW staff as a key resource for addressing social needs. Reported areas of support included housing navigation, transportation to appointments, insurance benefit enrollment, and access to food or home health services.

Some participants described specific technical challenges with digital platform use. Most issues related to device connectivity, syncing delays, or sensor functionality. For example, as one participant shared,

Other participants had intermittent issues with blood pressure measurement accuracy or precision. Participants expressed preferences to wear the arm sensor while showering for ease of use. As the digital platform’s mobile app was embedded in an Android phone that needed to be carried with participants when leaving their home, some participants expressed interest in having an app that could be used on their personal phone to avoid this. Table 1 summarizes the 5 themes.

This study demonstrated that digital platform use was feasible and that CHW staff assisted in making the platform more approachable for patients. This work strengthens our understanding of the barriers and facilitators to home-based HF management by identifying patient experiences with a digitally enabled CHW intervention as a part of a pilot trial. Few studies have examined patient experience with digital health interventions in the context of clinical trials. This work deepens the context of patient-centered HF home management identified in our previous studies [18,21] and other prior qualitative studies on HF [23].

Participants indicated that CHW care made the use of the digital platform more acceptable for patients. While CHW care is traditionally applied to social risk navigation [24,25], the use of CHWs specifically in digital trials for HF is novel and represents another way that CHWs can contribute to the landscape of care for patients facing HF at home [26]. Using CHW care along with HF digital platforms may help mitigate barriers to adoption and usability of digital platforms [27-29]. Despite patient hesitation regarding use of digital modalities to manage their health [30], our study findings highlighted positive participant responses regarding use of the digital platform. A recent cross-sectional study of patients with HF found that while only 22% of respondents reported prior use of health-related mobile apps, 53% of respondents expressed interest in using one for future self-management [31]. This suggests that patient interest in use of digital platforms may exceed actual use. Coimplementation of digital strategies with CHW or navigator support, even for a time-limited initiation interval for patients, could be an effective strategy for lowering barriers to digital health adoption among patients with HF.

Participants indicated that routine completion of home-based self-management skills such as monitoring home blood pressure, weight, and taking medications improved with the intervention. This is consistent with other remote monitoring studies in HF and chronic disease [32,33]. While this intervention was only 30 days in length, management skill uptake and integration into daily routines is a critical first step toward reducing preventable readmissions and improving postdischarge care transitions. One national survey of recently hospitalized patients with HF found that those who tracked their weight daily were significantly more likely to seek help for fluid retention than those who did not [34]. A number of small observational studies and trials evaluating mobile apps in HF populations have noted similar findings with improved clinician-patient communication, self-care, and engagement [35,36].

Given the established link between unmet social needs and heightened risk of HF readmission [37,38], our findings underscore the value of CHW care in efforts to help reduce risk associated with urgent and emergent care use. Participants indicated that CHW staff were helpful in assisting with navigating unmet social needs such as receiving assistance with housing, transportation, older adult services, and federal benefits navigation. By addressing health-related social needs such as those that are often associated with increased health care use, CHW care can improve care at home after discharge. These findings align with CHW core competencies and emphasize the impact of CHWs in chronic disease management [39-41]. In some cases, participants also reported learning how to engage with service agencies independently, suggesting that the intervention promoted some skill-building in this area.

We found that although participants frequently credited CHW care with enhancing their clinical knowledge of HF through personalized health care coaching, few used the digital library of educational videos associated with the mobile app. These videos were expected to be a key source of asynchronous learning and skill-based reinforcement for patients. However, despite frequent use of other aspects of the digital platform (eg, digital blood pressure cuff, weight scale, and daily questionnaire), few participants watched the videos with regularity despite encouragement from CHWs. This highlights the challenge associated with how patients access aspects of digital interventions. In retrospect, the 3-item task list for daily completion of platform activities that patients used each day did not include the videos as an itemized task. Incorporation of an option to watch educational videos as a part of the task list may augment use if adopted in future mobile app iterations.

Finally, several participants identified technical challenges related to digital platform use. Prior to the performance of this study, we conducted an open pilot trial (single arm) specifically designed to optimize workflow integration and identification of any technical issues related to the digital platform [18]. Despite the identification and reconciliation of digital platform connectivity, syncing, capture, and accuracy issues in the prior open pilot trial, participants in this study experienced a number of technical challenges. Previous studies have shown that technical glitches in remote monitoring devices can lead to decreased patient adherence and trust [42,43]. In HF-focused digital platforms, the importance of reliable operability and connectivity cannot be overemphasized [44]. Ultimately, performance accuracy and precision will decide which digital platforms merit larger-scale integration in health systems.

This study has limitations. First, participants were recruited from a single large urban academic medical center, which may limit the generalizability of findings for patients in community or rural health systems. Second, because enrollment was limited to patients recently hospitalized for HF, the sample may reflect individuals with greater clinical and social complexity than the broader HF population. Although there are numerous studies examining digital platforms in HF cohorts [45,46] and examining CHW care in chronic disease or cardiovascular populations [47,48], the ability to discern specific effects of either the digital platform or CHW care alone within this study is limited. Although the study guide was comprehensive and thematic saturation was achieved, some patient perspectives may have still been underrepresented, particularly those of individuals who were less engaged. Finally, resource constraints limited trial enrollment eligibility to those with English proficiency, which may have excluded specific perceptions experienced by those patients fluent in languages other than English. We also acknowledge that insights from the control group were not included here and may have provided additional findings. Despite this, we believe that these limitations were balanced by a robust study design with authentic responses gathered from participants engaged in this study.

This qualitative study demonstrated that patients with HF reported positive experiences with a digitally enabled CHW intervention. Most of the participants expressed that the components of the intervention worked well together and that the CHW care reduced barriers to platform use. These findings can inform digital and CHW home HF management for cardiac and primary care teams caring for this population. Further research is needed to better understand the facilitators and barriers to implementing this type of intervention in larger HF populations.