By Pareasa Rahimi
Improving health outcomes across Alabama has long been a priority for the University of Alabama at Birmingham School of Nursing. Located on a leading academic medical campus, the School is positioned to contribute its expertise and clinical partnerships to the care of patients across the state, including through the nurse-managed UAB Heart FailuRe Transitional Care Services for Adults (HRTSA) Clinic.
The interprofessional, collaborative clinic was established in 2014 through a three-year $1.5 million grant to now-Dean and Fay B. Ireland Endowed Chair Maria R. Shirey, PhD, MBA, RN, NEA‐BC, ANEF, FACHE, FNAP, FAAN. Shirey and Professor and Senior Director in the Center for Nursing Excellence at UAB Hospital Connie White-Williams, PhD, RN, NE-BC, FAHA, FNAP, FAAN (MSN 1991, PhD 2009), implemented the clinic for underinsured and/or medically underserved patients with heart failure discharged from UAB Hospital.
“Improving readmission rates by addressing the complex needs of heart failure patients was the primary objective for establishing the clinic,” Shirey said. “Many patients face barriers that make it difficult to access timely specialty care, often leading to worsening health concerns over time. Through this sustainable model of care, we have been able to address those challenges and provide the support patients need to achieve favorable outcomes.”
The clinic has been operated by UAB Medicine since 2017 and includes a team of nurse practitioners, clinical nurse leaders, social workers, registered nurses, certified medical assistants, a collaborating physician, behavioral health counselors, pharmacists, health professionals and office staff. The team practices a transitional care model seeing patients in the hospital, in clinic and in the home with the goals of better coordinating their care, improving quality of life and reducing 30-day hospital readmissions. Together, they provide comprehensive, guideline-directed medical therapy while also helping patients obtain essential medications, addressing food insecurity and providing education for patients and their caregivers.
“When interprofessional healthcare professionals work together in the same space, we can deliver safer, more coordinated and truly optimal care for every patient,” White-Williams said.
The clinic’s patient-centered approach helps eliminate barriers to care, ensuring individuals can access the services and support they need. Among the patient population, 87 percent do not have insurance or are underinsured, 40 percent have no income, 29 percent live on less than $10,000 a year and 79 percent are unemployed. More than 58 percent are impacted by food insecurity and have difficulty obtaining life sustaining medications.
As part of the UAB Nursing Partnership, the clinic employs the STAND-UP (Smooth Care Transitions for Diverse and Underserved Populations) model to integrate interprofessional education with collaborative care for individuals managing chronic conditions. Students from a variety of disciplines learn in a team-based environment that reflects real-world practice. By serving as a clinical training site for both undergraduate and graduate students, the clinic helps develop future healthcare professionals equipped to provide high-quality, coordinated care.
“Not only do we provide guideline-directed medical therapy and education to our patients and their families, we also address their social determinants of health,” said Vera Bittner, MD, MSPH, UAB Medicine Professor and Section Head of General Cardiology, Prevention and Imaging, and collaborating physician for the clinic. “Our goal is to provide our patients with resources that empower them to manage their heart failure and become good stewards of their own health.”
Patient-centered care driving improved health outcomes
The HRTSA Clinic team collaborates with UAB Hospital cardiologists, hospitalists and other affiliated providers who refer an average of 25-35 patients a month. Since its inception, the clinic has served more than 1,950 patients, maintaining continuity of care.
Carl David Bryant first visited the clinic eight years ago after experiencing two heart attacks and undergoing a procedure at UAB Hospital. He was referred to the HRTSA Clinic for a follow-up appointment and has remained under its care. He appreciates the clinic’s commitment to ensuring he has access to specialized services and has great confidence in the quality and consistency of the care he receives.
“I could not have asked for better care team,” Bryant said. “They’ve taken really good care of me. Whenever a health issue comes up, whether it’s my heart or my psoriasis, they make sure I see the right doctor at UAB. The team is great and is concerned about my well-being. I know I’m in good hands, and my health is a lot better.”
Anthony Simmons was referred to the clinic in 2020 while undergoing rehabilitation after surgery. He says the attentiveness and support of his providers make his four-hour roundtrip drive worthwhile.
“The clinic has helped improve and extend my life,” Simmons said. “The providers are patient and have gradually coached me into being better. They know my medical history and require follow-ups as often as needed so they can monitor my progress. There was a point when my legs were so weak that I could not walk and was a fall risk. I couldn’t even function without being short of breath. They have helped bring me from that stage to where I am today. If you had seen me then, you wouldn’t realize it was the same person.”
At the HRTSA Clinic, achieving optimal health outcomes is a partnership between providers and patients. Through evidence-based education, patients like Simmons and Bryant gain the knowledge and tools needed to manage their conditions, whether through healthier eating, increased physical activity or lifestyle changes. Clinic providers also prioritize creating an environment where patients feel comfortable sharing concerns, asking questions and engaging in open, honest conversations about their health.
“The most important thing I had to learn was how to eat healthier and exercise,” Simmons said. “I had to create a routine and check in with Dr. Carla Turner, the clinic’s Lead Nurse Practitioner. She gave me a list of things that I could eat and I made changes to the best of my ability. The team puts me at ease and it makes you want to be truthful because you feel comfortable.”
A model for academic-practice partnerships
The HRTSA Clinic is a nationally recognized illustration of a successful academic-practice partnership among the UAB School of Nursing, UAB Hospital Nursing and Cardiology, garnering several accolades for its model of healthcare delivery. The HRTSA Clinic was recognized in 2025 by the Heart Failure Society of America with the 2025 Outstanding Heart Failure Care Team Award. In 2020, the clinic and the School’s PATH (Providing Access to Healthcare) Clinic received a joint award for Creativity in Practice and Education Award from the National Academies of Practice.
The clinic team also has participated in multiple research endeavors over the years, leading to the dissemination of their work in 20 publications and through multiple local, national and international presentations. In 2020, White-Williams and Shirey were the lead and senior authors, respectively, on an American Heart Association statement paper designed to alert health care providers of the importance of social determinants of health for underserved patients with heart failure.
Most recently, leaders of the School’s clinical partnerships and nurse-managed clinics put their experience and knowledge behind their award-winning academic-practice partnerships into a new book, “Leading Academic‑Practice Partnerships in Nursing and Healthcare: A Paradigm for Change.” The book serves as a first-of-its-kind blueprint for creating and sustaining partnerships to provide better care for patients and education to students and is intended for other schools of nursing, academic and clinical leaders.
Authors of the book include Shirey; White-Williams; Dean and Professor Emerita Doreen C. Harper, PhD, RN, FAAN; Professor Emerita Cynthia Selleck, PhD, RN, FNP, FAAN; and Professor and Associate Dean for Clinical and Global Partnerships Michele H. Talley, PhD, CRNP, ACNP‐BC, FAANP, FNAP, FAAN (MSN 2005, PhD 2015).
“As healthcare systems face unprecedented workforce shortages and escalating demands for access and quality, academic–practice partnerships are no longer optional—they are essential,” Shirey said. “This book provides a proven framework to combine the best of human resources with expertise from the education and practice environments we have used to lead health and healthcare transformation.”