HEARTLAND Protocol: A Tiered Clinical Implementation Toolkit for Primary Care-Led Heart Failure Management in Rural and Resource-Limited Settings

Despite decades of evidence-based heart failure (HF) guidelines, no published implementation protocol provides a comprehensive, operational framework for primary care-led HF management specifically designed for rural and resource-limited settings in the United States. Existing quality improvement programs, such as Get With The Guidelines-Heart Failure, identify performance targets but do not provide step-by-step clinical protocols for achieving them in settings with minimal staffing, no specialist access, and limited digital infrastructure. Established HF risk scores similarly omit rural-specific determinants of outcome, including distance to cardiology care and social support, despite robust evidence of their prognostic relevance. The HEARTLAND Protocol (Heart failure Evidence-based Access in Rural Treatment, Linking Advanced Network Delivery) addresses these gaps through a clinical implementation toolkit comprising eight integrated modules that cover the care continuum from hospital admission through long-term management. Developed through a targeted narrative review of clinical evidence published between 2018 and 2025 and informed by the Consolidated Framework for Implementation Research, the protocol synthesizes validated interventions into a tiered structure designed for deployment across varying resource levels. Key features include a three-tier implementation framework accommodating settings from severely constrained critical access hospitals to well-resourced regional centers, a dual-track system supporting both digital and analog monitoring pathways validated by the Hozhó Trial, a pharmacoeconomic generic bridge pathway ensuring that no patient remains untreated due to cost barriers, and a supplementary risk score incorporating rural-specific variables not captured by existing prognostic instruments. The protocol distinguishes between established guideline-supported evidence, emerging trial findings, and pragmatic clinical heuristics, maintaining transparency about evidence strength and methodological limitations throughout. HEARTLAND provides a practical, adaptable framework to extend evidence-based HF care to underserved communities while preserving scientific rigor and positioning facilities for emerging value-based payment models.