Improving Post-Heart Attack Care for Hispanic Patients: A Culturally Tailored Discharge Model (HAMIDI)

Hispanic patients experience well-documented disparities following acute myocardial infarction (AMI), including higher 30-day readmission rates and lower referral to cardiac rehabilitation compared to White patient populations. These inequities are often driven by structural and communication barriers, including delayed recognition of symptoms, limited language-concordant care, and challenges navigating complex discharge instructions and follow-up services. During the high-risk period of transition from hospital to home, these barriers can make recovery more difficult and increase the risk of poorer outcomes.

This recognition helped inspire the development of the Hispanic Acute Myocardial Infarction Discharge Intervention Study (HAMIDI), a culturally tailored care model designed to support Hispanic patients during a vulnerable period of recovery. As project lead Dr. Jonathan Ludmir reflected, commonly hearing patients say “I don’t understand what was told to me” highlighted the disconnect many Spanish-speaking patients experience during hospitalization and recovery.

The 6-month post-discharge HAMIDI program combines structured clinical follow-up with culturally and linguistically responsive support. Participants are connected with Spanish-speaking cardiologists, participate in 2-part virtual group education focused on nutrition and physical activity, and receive ongoing care coordination throughout the recovery process. Project support staff also provide practical, hands-on support, helping patients and families navigate appointment scheduling, follow-up communication, surveys, and technology needed for virtual visits.

• At the first outpatient visit, the patient receives standard post-AMI care in Spanish. If lipid levels or A1C weren’t checked before discharge, those labs are drawn at this visit. A referral to cardiac rehab is also placed if it hasn’t already been done.
• In addition to this routine care, the patient is invited to join the virtual group visit program. Patients then return for follow-up—either in person or virtually—around the 6-month mark (or sooner if needed), at which time labs are repeated.
• The virtual group visits focus on lifestyle changes, especially plant-based nutrition and exercise.
• Each session includes a 15–20 minute overview of key lifestyle strategies along with motivation tips, followed by patient check-ins and group discussion.
• Patients complete surveys before starting and after finishing the program, which assess their knowledge, attitudes, and behaviors related to lifestyle changes, as well as their overall feedback on the program.

By embedding language-concordant care, culturally responsive education, and hands-on navigation into the discharge process, HAMIDI offers a practical model for improving continuity of care, strengthening patient engagement, and advancing more equitable cardiovascular outcomes.

During the first year of implementation:

• 45 patients enrolled in the program, 80% of whom had limited English proficiency
• 35 patients (78%) participated in at least one follow-up visit or group session
• 30-day readmissions for the 35 participants who participated in follow-up decreased to 17.1% (compared to a national average of 23%) and 30-day mortality decreased

Key findings from early implementation include:

• Strong participation in both clinical follow-up and group-based education
• Feasibility of combining virtual and in-person care models to increase access
• High engagement among patients with limited English proficiency when culturally tailored services are provided

Rather than relying on standard discharge protocols, HAMIDI demonstrates how culturally tailored, longitudinal support can improve engagement and continuity of care during a high-risk transition period to achieve better outcomes.

Implementation of the HAMIDI program required:

• Spanish-speaking cardiologists and bilingual care teams (Note: for care teams who do not serve predominantly Spanish-speaking communities and for whom this is not feasible, ensure appropriately trained translators)
• Dedicated coordinators to support patient navigation
• Infrastructure for virtual group visits and hybrid care delivery
• Adaptation of an existing post-MI reduction platform to include culturally tailored components
• Ongoing training and alignment among cardiology faculty and staff

The program leveraged existing clinical systems while integrating culturally responsive modifications, supporting feasibility within a large academic health system.

Challenges encountered included:

• Lack of standardized discharge models tailored for Hispanic patients
• Language barriers across clinical and administrative interactions
• Technology access and digital literacy limitations for virtual care
• Variability in patient engagement across follow-up components
• Structural barriers related to education level and health literacy

These barriers highlight the importance of designing interventions that extend beyond clinical care to address social and structural determinants of health.

Key elements that are potentially scalable include:

• Use of language-concordant care teams
• Integration of virtual group-based education
• Embedding care coordination into discharge processes
• Adapting existing clinical pathways to include culturally tailored components
• Development of site-specific champions to support implementation

Currently, the program is implemented at the main clinic at the MGH and two MGH-affiliated community sites. The program is being considered for expansion across the Mass General Brigham health system, with the goal of creating similar models for patients with non-English language preferences.

Sustaining this model of care will require:

• Continued investment in bilingual and culturally responsive workforce development
• Integration of program components into standard care pathways
• Long-term funding to support care coordination and patient navigation (Note: Principal Illness Navigation (PIN) billing codes can be used to subsidize costs)
• Institutional commitment to addressing disparities in cardiovascular care

Embedding culturally tailored interventions into routine discharge processes may support long-term sustainability and broader impact.

• Incorporate culturally and linguistically tailored care into discharge planning from the outset
• Provide structured follow-up early after discharge, combining clinical care with education and navigation support
• Use flexible care models (virtual and in-person) to increase accessibility, and address technology barriers proactively
• Identify institutional champions to support implementation and scaling

Jonathan Ludmir, MD

Gisella A. Suero-Abreu, MD

Ayda Gonzalez de la Nuez, MD

Martin Robles

Malissa J. Wood, MD

Marcela G. del Carmen, MD

Jason H. Wasfy, MD

• Interdisciplinary Cardiology and Research Team
  Massachusetts General Hospital / Mass General Brigham Health System