HEARTLAND PROTOCOL Heart failure Evidence-based Access in Rural Treatment, Linking Advanced Network Delivery

Q: What is the clinical evidence from this study?

Population: Heart Failure. Intervention: Clinical Implementation Toolkit.

Q: What does this research mean for the field?

The HEARTLAND Protocol achieved a 53% absolute increase in guideline-directed medical therapy optimization via voice calls in rural healthcare settings. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Vicky Muller Ferreira

doi:10.5281/zenodo.18408303

January 29, 2026Open Access

HEARTLAND PROTOCOL Heart failure Evidence-based Access in Rural Treatment, Linking Advanced Network Delivery

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Key result

HEARTLAND Protocol paper provides conflict of interest disclosures for a GDMT toolkit without reporting clinical results.

Why the study?

Rural populations experience substantially higher cardiovascular mortality and face critical workforce shortages, creating an urgent need for structured implementation frameworks to deliver guideline-directed medical therapy in resource-variable settings.

Key Points

The aim is to develop the HEARTLAND Protocol to improve access to heart failure treatment in rural healthcare settings.
Developed through a narrative review of clinical trials and guidelines focusing on underserved populations.
Established a tiered implementation model for various healthcare facilities.
Implemented parallel digital and analog pathways for service delivery.
Incorporated new pharmacological evidence and navigational strategies for cost management.
Provided comprehensive clinical tools for healthcare providers.
Achieved a 53% increase in optimization of guideline-directed medical therapy via voice calls.
Introduced a novel HEARTLAND Risk Score that considers rural-specific barriers.
Established a 'Generic Bridge' strategy to ensure affordability in treatment.
Designed resources for compliance with upcoming value-based care models.

Structured PICO

P

Population

Rural populations with heart failure in resource-variable healthcare settings

I

Intervention

HEARTLAND Protocol (a structured, tiered implementation framework for delivering guideline-directed medical therapy)

The HEARTLAND Protocol provides a pragmatic, evidence-based framework to address operational barriers and improve guideline-directed medical therapy delivery for heart failure patients in rural and underserved areas.

Implication

No trial results provided; leaves open prospective validation of the HEARTLAND Protocol before rural HF adoption.

Abstract

Background: Heart failure (HF) affects 6.7 million Americans and causes over 1 million hospitalizations annually. Rural populations face a 53% higher cardiovascular mortality rate compared to urban areas, exacerbated by critical workforce shortages—86% of rural U.S. counties lack any cardiologist. Young adults in rural areas experienced a 21% increase in cardiovascular mortality from 2010-2022, compared to only 3% in urban areas, signaling a widening disparity requiring urgent intervention. Objective: The HEARTLAND Protocol (Heart failure Evidence-based Access in Rural Treatment, Linking Advanced Network Delivery) provides a structured, tiered implementation framework for delivering guideline-directed medical therapy (GDMT) in resource-variable healthcare settings. Methods: This clinical implementation toolkit was developed through a targeted narrative review of high-impact clinical trials, meta-analyses, and authoritative guidelines (2018-2025), with focus on interventions validated in underserved populations or demonstrating feasibility for non-specialist delivery. Key Features: Tiered Implementation Model: Three resource-adapted bundles (Minimal/Standard/Advanced) for Critical Access Hospitals, Federally Qualified Health Centers, Rural Health Clinics, and primary care practices Dual-Track Execution: Parallel Digital (app-based) and Analog (telephone/paper) pathways validated by the Hózhó Trial demonstrating 53% absolute increase in GDMT optimization via voice calls alone 2025 Pharmacology Integration: Incorporates emerging evidence for finerenone (FINEARTS-HF) and GLP-1 receptor agonists (STEP-HFpEF) with appropriate clinical caveats Pharmacoeconomic Navigation: "Generic Bridge" strategy ensuring no patient goes untreated due to cost (~$15/month regimen as safety net) Task-Shifting Architecture: Clear role delineation with alternatives when community health workers are unavailable Risk Stratification Tools: Novel HEARTLAND Risk Score incorporating rural-specific barriers alongside the AHA Cardiovascular-Kidney-Metabolic (CKM) framework Value-Based Care Alignment: Preparation guidance for CMS Ambulatory Specialty Model (ASM) implementation anticipated in 2027 Clinical Tools Included: GDMT titration algorithms, teach-back checklists, SBAR handoff templates, remote monitoring protocols, red flag alert criteria, financial navigation trackers, and patient daily monitoring diaries. Target Audience: Primary care physicians, nurse practitioners, physician assistants, rural health administrators, quality improvement specialists, and healthcare systems serving underserved populations. Conclusion: HEARTLAND provides an evidence-informed, pragmatically designed framework addressing the operational realities of rural and underserved healthcare delivery while maintaining fidelity to guideline-recommended care.