Fig. 1.

PArTNER study design.

In the PArTNER study, participants hospitalized with a physician diagnosis of heart failure, pneumonia, chronic obstructive pulmonary disease (COPD), myocardial infarction, or sickle cell disease are randomly allocated to one of two groups: Navigator intervention or Usual care. The Navigator intervention spanned over a 2-month period after hospital discharge and included: 1) community health workers (CHWs) who conducted in-person study visits in the hospital and a single home visit 1–3 days post-discharge to assess barriers to patient-centered transitions from hospital to home, and 2) peer coaches are introduced on hospital discharge and contact participants via telephone at approximately 1, 2, 3, 5, and 7 weeks post-discharge to continue supports initiated by CHWs. Following in-person baseline data collection prior to randomization, follow-up outcomes were assessed via telephone at 30 days and 60 days post-discharge.