CARE-HOME-HF: An integrated heart failure screening and management pathway across nursing home, home hospital and cardiogeriatric day hospital

Background

Heart failure (HF) is highly prevalent among older adults in nursing homes, where it remains frequently underdiagnosed and suboptimally managed. Multimorbidity, frailty and cognitive impairment often mask cardiac symptoms, while limited access to specialized care contributes to therapeutic inertia and delayed intervention. Communication between long-term care facilities, home hospital (HAD) teams and cardiology services is frequently fragmented, leading to uncoordinated management and potentially avoidable hospitalizations. Innovative, pragmatic and integrated models of HF care tailored to institutionalized older adults are urgently needed.

Purpose

To assess the feasibility and early outcomes of an integrated, multidisciplinary HF pathway linking a nursing home, a home hospital and a cardiogeriatric day hospital, designed to facilitate early detection, therapeutic optimization and decompensation management directly within the resident’s care setting.

Methods

A coordinated initiative was developed between a nursing home (EHPAD), a home hospital (HAD) structure, and a cardiogeriatric day hospital within the same healthcare network.

Screening targeted residents with (1) a documented diagnosis of HF, (2) ongoing diuretic therapy, or (3) atrial fibrillation. All eligible residents underwent cardiogeriatric review, and subsequent orientation was determined collaboratively according to clinical status and frailty.

Results

Among 76 residents, 28 (37%) met ≥ 1 screening criterion. Six were excluded (5 without confirmed HF, 1 refusal).

Of the 22 patients included:

• 2 were optimized on-site with the introduction of an SGLT2 inhibitor;

• 10 were enrolled in telemonitoring;

• 5 were referred for day-hospital reassessment and titration, including echocardiography;

• 22 had a "dormant" HAD file enabling immediate IV diuretic therapy if decompensation occurred;

• 10 very frail patients entered a palliative HAD pathway, allowing IV diuretics on-site without planned hospitalization, while hospital admission remained possible for others if decongestion failed.

Implementation proved feasible through structured communication channels, shared protocols and regular joint reviews between EHPAD, HAD and cardiogeriatric teams, enhancing local coordination and staff empowerment.

Conclusion

The CARE-HOME-HF pilot demonstrates the feasibility and strong acceptability of an integrated, cross-sectoral model for HF management in institutionalized older adults. By bridging nursing-home, HAD and cardiogeriatric services, this initiative provides a pragmatic framework for early identification, personalized therapy and safe decompensation management directly where patients live. This multidisciplinary, reproducible and scalable model supports ESC 2021 recommendations for integrated HF care and could help reduce avoidable hospitalizations while fostering patient-centred, territorial cardiogeriatrics.