Inclusion Criteria for patient participant:  Adult HF patients Hospitalized >48 hours at Hôpital-Universitaire de Mirebalais (HUM) Anticipated discharge from HUM within 1-3 days Living in Mirebalais Commune, Haiti Inclusion criteria for historical patient reference group Adult HF patients Hospitalized >48 hours at HUM Discharged from HUM within the 12 months preceding the intervention Living in Mirebalais Commune  Exclusion Criteria for patient participant and historical patient reference group:  None  Inclusion Criteria for CHW  Adult Provide inpatient or outpatient care to HF patients Working in in Mirebalais  Exclusion Criteria for CHW  None  Inclusion criteria for healthcare staff (provider/administrator)  Hospital leadership involved in supervision of clinical care programs (i.e. Chief Executive Officer, Chief Medical Officer, Chief Operations Officer, Chief Nursing Officer, etc.) Leaders of the Community Health Department - including the nurse Director of Community Health, and Community Health Worker Supervisors. Healthcare providers at HUM involved in the care of patients with heart failure (i.e. internal medicine physicians, inpatient hospital nurses, outpatient clinic physicians, outpatient clinic nurses, etc.)  Exclusion criteria for healthcare staff (provider/administrator)  None