PROJECT SUMMARY/ABSTRACT This career development award will establish Dr. Oanh Nguyen as a clinician-investigator focused on designing, implementing, and evaluating transitional care interventions to improve health outcomes for vulnerable patients with cardiovascular illness. This award will provide support needed to develop her expertise in: 1) advanced methods in patient-centered outcomes research (PCOR); 2) social determinants of health; and 3) intervention development, implementation, and evaluation in real-world health settings. To achieve these goals, Dr. Nguyen has assembled an expert mentorship team. Her primary mentor, Ethan Halm, MD, MPH, has extensive experience in health services research, PCOR, predictive modeling, intervention development, and training and mentoring faculty. Her co-mentor, Simon Lee, PhD is a medical anthropologist with expertise in qualitative methods, PCOR, and implementation science. Additional scientific advisors include Song Zhang, PhD, an expert in advanced biostatistics and predictive modeling techniques; and Sandeep Das, MD, an expert in implementation and evaluation of evidence-based cardiovascular care delivery interventions. Readmission within 30 days of hospitalization occurs in up to 1 in 5 adults, and patients with congestive heart failure (CHF) and ischemic heart disease (IHD) are among those at highest risk. Despite federal financial `readmissions penalties' for cardiovascular and other conditions, the most effective strategy to prevent readmissions remains unknown. Current interventions focus on improving medical care processes, but do not address deeper social vulnerabilities such as food and housing insecurity or behavioral health needs associated with higher readmission risk. Informed by her clinical experience and preliminary studies, Dr. Nguyen will conduct a series of studies to: 1) develop predictive models to identify hospitalized patients with CHF and IHD at high risk for readmission, and to stratify individuals by medical severity and social vulnerabilities (Aim 1); 2) conduct qualitative interviews of high-risk patients to understand patient perspectives on how social vulnerabilities affect medical recovery from CHF and IHD, and on the acceptability of community- based interventions to address these vulnerabilities (Aim 2); and 3) develop, pilot, and assess the feasibility of a transitional care intervention enhanced to address social vulnerabilities in addition to traditional medical needs (Aim 3), incorporating an innovative social-health information exchange (Dallas Information Exchange Portal). This research plan leverages existing institutional resources, including Dr. Halm's AHRQ-funded UT Southwestern (UTSW) Center for PCOR; the UTSW CTSA; and novel information technology. This training and research will form the basis for an R01 application for a fully powered randomized controlled trial to assess the impact of a risk-stratified readmission prevention strategy that addresses bot...