Bridging inequity in HFpEF care: pilot project experience informing the design and implementation of a multidisciplinary blueprint
M Lee, Y Millerick, J Taylor, A Anand, S Bagnall, K J M Brooksbank, R Davison, J Dhillon, K Gray, A Lees, S Odigbo, Y Philipson, J Stirton, M C Petrie, K J HoggAbstract
Background
Heart failure with preserved ejection fraction (HFpEF) is a leading cause of cardiovascular morbidity, yet integrated care pathways remain underdeveloped. Clinical heterogeneity, multimorbidity, and historically limited disease-modifying therapies have resulted in fragmented care and inequity compared with heart failure with reduced ejection fraction. Across health systems, HFpEF remains underdiagnosed, with low uptake of guideline-directed medical therapy, prolonged hospitalisation, and limited specialist follow-up, highlighting the need for system-level redesign.
Purpose
To describe the rationale, design, and early implementation of a multidisciplinary HFpEF pilot project, and to present a scalable service blueprint for integrated care.
Methods
A multidisciplinary HFpEF pilot project was launched in March 2024 within a large urban regional health system to deliver an integrated pathway from referral to evaluation (Figure). Referrals are accepted from primary care, outpatient, and inpatient settings. Patients are triaged into three stratified groups based on clinical stability, multimorbidity burden, and anticipated care needs, with dynamic movement between groups over time. Care is delivered by a multidisciplinary team (MDT) comprising cardiology, care of the elderly, heart failure specialist nursing, pharmacist, pharmacy technician, and administrative support, with links to existing allied health professionals and specialty services as appropriate. Care delivery is enabled through pathways promoting early supported discharge, rapid near me review, and hospital avoidance strategies delivered across inpatient, outpatient, community, and virtual care settings. Core interventions include diagnostic confirmation, therapy optimisation, comprehensive review including frailty and psychosocial assessment, and education to empower self-management. Phased implementation included protocol development, workforce training, electronic data capture, and stakeholder engagement.
Results
The pilot project is operational and demonstrates the feasibility of an integrated, home-first model of HFpEF care. Early experience suggests that structured MDT decision-making supports diagnostic accuracy, timely therapy optimisation, and coordination across care settings. An evaluation framework captures process metrics, patient, carer, and staff experience, and clinical outcomes, with linkage to routine electronic health records and improved access to audit, quality improvement, and research.
Conclusions
This pilot represents a redesign of HFpEF care delivery for a historically underserved population. By integrating broad referral access, stratified triage, multidisciplinary delivery, and embedded evaluation, it provides a scalable blueprint for modern HFpEF care. Ongoing evaluation will define its impact on outcomes and health system utilisation.HFpEF Pilot Project - Service BlueprintFor image description, please refer to the figure legend and surrounding text.