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

This study targets disparities in cardiometabolic disease prevalence and outcomes, and the
unmet behavioral health needs in the US Hispanic population. 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 are likely the
result of an interaction of several multi-level factors, such as those related to low SES
(e.g., lack of transportation or health coverage, time constraints, unsafe environments,
knowledge barriers), cultural factors, language or communication-style differences, and
others. Mi Puente (or "My Bridge") is a culturally-tailored, interdisciplinary approach
designed to support at-risk Hispanic patients and their caregivers pre- and post-hospital
discharge as they navigate the multi-level barriers that contribute to inequities in health
care access and use, and in turn, perpetuate disparities in cardiometabolic and behavioral
health. Mi Puente builds upon a sustainable nurse + volunteer peer team-based model and a
strong collaborative, bridging partnership between inpatient and outpatient care settings to
meet the integrated (i.e., physical and behavioral) health needs of Hispanics who are
hospitalized with multiple chronic cardiometabolic conditions and one or more behavioral
health concern(s). The program is guided by the Social Ecological Model,34 Resources and
Support for Self-Management Model,35,36 and Transtheoretical Model of behavior change,37,38
and will be tested at Scripps Mercy Hospital - a large, non-profit, safety net hospital
located in the US/Mexico border region of South San Diego County, CA. The proposed randomized
controlled trial will test Mi Puente versus Usual Care (evidence-based, best practice
discharge procedures) in improving hospital utilization, patient-reported, and cost
effectiveness outcomes. Electronic medical records (EMR) will be used to identify eligible
patients and examine primary outcomes. Ultimately the investigators seek to evaluate an
effective, culturally appropriate, sustainable, and scalable program that addresses
integrated health needs and reduces health disparities in Hispanics and other at-risk
populations.

Inclusion Criteria:

1. Must be Hispanic

2. Must be ≥18 years

3. Must have ≥2 cardiometabolic conditions (e.g., obesity, diabetes, hypertension,
dyslipidemia ischemic heart diseases, congestive heart failure, other chronic coronary
conditions)

4. Must have ≥1 behavioral health concern(s) (i.e., related to mental health, life
stressors, medication adherence, healthcare use)

5. Must have telephone access

Exclusion Criteria:

1. Pregnancy

2. Serious life-threatening condition with life expectancy < 6 months

3. Psychiatric morbidity or neurological/cognitive impairment of sufficient severity to
preclude participation in the intervention

4. Discharging to location other than home (e.g., nursing care)

5. Does not speak Spanish or English