Implementing an integrated cardiogeriatric pathway for heart failure in long-term care: the CARE-HOME-HF pilot

Purpose Very elderly patients with heart failure (HF) living in long-term care facilities (LTCFs) frequently experience fragmented care, avoidable emergency department transfers, and suboptimal treatment optimisation. We aimed to describe the implementation and early care delivery outcomes of an integrated cardiogeriatric pathway designed to improve coordination, clinical decision-making, and continuity of care across settings. Design/methodology/approach We conducted a prospective, single-centre pilot implementation study in one LTCF, based on a multidisciplinary cardiogeriatric model coordinated by advanced practice nurses (APNs). The pathway integrated systematic screening, telemonitoring (Satelia® Cardio), shared electronic medical records, structured multidisciplinary reviews, and pre-activated hospital-at-home (HAH) care plans. Feasibility indicators, care delivery metrics, and descriptive outcomes were prospectively collected. Findings Among 76 residents screened, 22 patients were enrolled. Telemonitoring was implemented in 10 patients (45.5%). Five patients (22.8%) benefited from cardiogeriatric day-hospital assessment, and two (9.0%) underwent on-site treatment titration. Anticipatory care planning included the pre-activation of a dormant HAH file for diuretic management in 20 patients (90.9%) and a palliative care HAH file in 11 patients (50.0%). The pathway enabled individualized, coordinated care adapted to patients' clinical status, frailty, and goals of care. Practical implications This pilot demonstrates the feasibility of an APN-coordinated, integrated cardiogeriatric pathway for HF management in long-term care, combining telemonitoring, anticipatory care planning, and cross-setting coordination. Originality/value CARE-HOME-HF represents a novel, scalable model operationalising European recommendations for multidisciplinary, function-centred care in very old adults and corresponds to the feasibility stage of the UK MRC framework for complex interventions.