Frailty-based cardiogeriatric pathway for heart failure: a multidisciplinary, age-friendly model
R Esser, M Esteban, C Farges, M Larbaneix, A Mondragon, C Nouhaud, C Donadio, B Merat, A Darmon, L M Desroche, S Nisse-Durgeat, O Maurou, M HarbounAbstract
Background
Heart failure (HF) in older adults is increasingly complex due to multimorbidity, frailty, and functional and cognitive decline. Conventional cardiology models often fail to address these dimensions, resulting in fragmented care and functional deterioration. Addressing frailty and functional reserve within HF pathways is a cornerstone of the 2021 ESC guidelines but remains under-implemented in real-world practice. Integrating geriatric principles into cardiovascular care is essential to achieve safe, personalized, and value-based management for aging populations.
Purpose
To describe the design and early outcomes of an integrated cardiogeriatric HF pathway embedding frailty stratification, comprehensive geriatric evaluation, and multidisciplinary coordination to optimize decision-making, care transitions, and patient-centered outcomes.
Methods
A multidisciplinary taskforce of cardiologists, geriatricians, nurses, and rehabilitation specialists co-developed a structured algorithm aligned with the Age-Friendly Health Systems framework and the WHO Integrated Care for Older People (ICOPE) approach. Patients are categorized into three profiles—fit, frail, and palliative—according to functional reserve, comorbidity burden, and goals of care. Each pathway operationalizes the 4Ms framework (What Matters, Medication, Mentation, Mobility) to guide tailored interventions across acute, post-acute, day-hospital, and community care. Advanced practice nurses (APNs) ensure coordination, telemonitoring follow-up, and early response to decompensation or functional decline.
Results
Since implementation in 2023, the model has proven feasible and sustainable within a tertiary care network. Frailty-based stratification standardized therapeutic intensity, improved interdisciplinary communication, and strengthened transitions between hospital and community care. Embedding the 4Ms framework aligned care with patients’ functional status and personal goals, reinforcing autonomy and safety. Early feedback indicates enhanced continuity of care, improved patient satisfaction, and high clinician engagement, confirming the model’s clinical relevance and acceptability.
Conclusion
This cardiogeriatric HF pathway demonstrates that integrating frailty assessment and geriatric principles into HF management is both feasible and transformative. By bridging cardiology and geriatrics, it operationalizes ESC 2021 recommendations for integrated, multidisciplinary, and person-centered care. The model offers a replicable and scalable framework to reduce fragmentation, preserve independence, and deliver age-friendly cardiovascular care for frail older adults.For image description, please refer to the figure legend and surrounding text.