UAB Clinic Group Shot

UAB Heart Failure Transitional Care Services for Adults (HRTSA) Clinic


2025 Outstanding Heart Failure Care Team Award Winner

The UAB Heart Failure Transitional Care Services for Adults (HRTSA) Clinic at the University of Alabama at Birmingham (UAB) Hospital, is an interprofessional collaborative practice clinic that provides care to underserved patients with a diagnosis of heart failure. The clinic, which evolved from an Academic-Practice partnership, is a nurse-led interprofessional collaborative practice that provides care for underserved patients with a diagnosis of heart failure in some of the most economically disadvantaged areas in Alabama. For our clinic, underserved is defined as individuals who are uninsured, underinsured, and/or lack a consistent medical home. The team’s mission is to provide guideline directed care and education to underserved patients with heart failure and their caregivers regardless of their socioeconomic status, race, ethnicity, social support, or health literacy level. The overarching goal of the HRTSA Clinic is to optimize heart failure treatment, prevent unnecessary emergency department visits and hospital readmissions, and offer compassionate, patient-centered care. The HRTSA team proactively addresses social determinants of health (SDOH) and implements evidence-based interventions that have resulted in measurable improvements in clinical outcomes. Together, this team provides comprehensive, wraparound support, including access to care, life sustaining medications, behavioral health, healthy food, and resources such as scales, blood pressure cuffs and pillboxes to promote effective self-care. All patients receive interprofessional care by a team of APPs, nurses, social workers, pharmacists, health professionals, behavioral health counselors, and public health experts. Additionally, the clinic also serves as a robust clinical training site for nursing, pharmacy, social work, and health professions students, nurturing the next generation of compassionate and competent healthcare professionals. The clinic team works closely with hospital cardiologists and hospitalists who refer an average of 35 patients a month. Since its inception, this clinic has served over 1700 underserved patients. The team practices a transitional care model seeing patients in the hospital, in clinic, and in the home. We have participated in multiple research endeavors over the years which has led to the dissemination of our work with 20 publications and multiple local, national, and international presentations.