HEARTLAND PROTOCOL Heart failure Evidence-based Access in Rural Treatment, Linking Advanced Network Delivery

Background: Heart failure (HF) affects 6.7 million Americans and causes over 1 million hospitalizations annually. Rural populations face a 53% higher cardiovascular mortality rate compared to urban areas, exacerbated by critical workforce shortages—86% of rural U.S. counties lack any cardiologist. Young adults in rural areas experienced a 21% increase in cardiovascular mortality from 2010-2022, compared to only 3% in urban areas, signaling a widening disparity requiring urgent intervention. Objective: The HEARTLAND Protocol (Heart failure Evidence-based Access in Rural Treatment, Linking Advanced Network Delivery) provides a structured, tiered implementation framework for delivering guideline-directed medical therapy (GDMT) in resource-variable healthcare settings. Methods: This clinical implementation toolkit was developed through a targeted narrative review of high-impact clinical trials, meta-analyses, and authoritative guidelines (2018-2025), with focus on interventions validated in underserved populations or demonstrating feasibility for non-specialist delivery. Key Features: Tiered Implementation Model: Three resource-adapted bundles (Minimal/Standard/Advanced) for Critical Access Hospitals, Federally Qualified Health Centers, Rural Health Clinics, and primary care practices Dual-Track Execution: Parallel Digital (app-based) and Analog (telephone/paper) pathways validated by the Hózhó Trial demonstrating 53% absolute increase in GDMT optimization via voice calls alone 2025 Pharmacology Integration: Incorporates emerging evidence for finerenone (FINEARTS-HF) and GLP-1 receptor agonists (STEP-HFpEF) with appropriate clinical caveats Pharmacoeconomic Navigation: "Generic Bridge" strategy ensuring no patient goes untreated due to cost (~$15/month regimen as safety net) Task-Shifting Architecture: Clear role delineation with alternatives when community health workers are unavailable Risk Stratification Tools: Novel HEARTLAND Risk Score incorporating rural-specific barriers alongside the AHA Cardiovascular-Kidney-Metabolic (CKM) framework Value-Based Care Alignment: Preparation guidance for CMS Ambulatory Specialty Model (ASM) implementation anticipated in 2027 Clinical Tools Included: GDMT titration algorithms, teach-back checklists, SBAR handoff templates, remote monitoring protocols, red flag alert criteria, financial navigation trackers, and patient daily monitoring diaries. Target Audience: Primary care physicians, nurse practitioners, physician assistants, rural health administrators, quality improvement specialists, and healthcare systems serving underserved populations. Conclusion: HEARTLAND provides an evidence-informed, pragmatically designed framework addressing the operational realities of rural and underserved healthcare delivery while maintaining fidelity to guideline-recommended care.