Building an integrated cardiogeriatric heart failure pathway for very old adults: a four-year community case study from Hôpital La Porte Verte

Heart failure pathways are often poorly adapted to very old adults, whose clinical trajectories are shaped by frailty, multimorbidity, cognitive impairment, functional decline, polypharmacy, caregiver dependence, and fragmented transitions between hospital, home, and long-term care settings. This Community Case Study describes the progressive construction, over nearly four years, of an integrated cardiogeriatric heart failure pathway at Hôpital La Porte Verte, Versailles, France. The pathway was developed iteratively through the phased implementation of complementary services, progressive clarification of professional roles, and repeated adaptation of coordination and escalation processes across inpatient, outpatient, home-based, and long-term care settings. Developed within a dedicated cardiogeriatrics department, the pathway connects acute inpatient care with structured post-discharge follow-up, remote monitoring, rapid-access day hospitals, advanced practice nurse-led coordination, hospital-at-home collaboration, long-term care facility outreach, pre-interventional geriatric evaluation, and palliative-oriented decision-making when appropriate. The central lesson is that integrated cardiogeriatric heart failure care should not be viewed as a single intervention, but as a responsive care architecture linking early detection, human triage, timely clinical response, reassessment, and continuity across settings. Remote monitoring is clinically meaningful only when connected to a trained response team and rapid-access care capacity; day hospitals function as reassessment platforms rather than simple alternatives to admission; and advanced practice nurses are key to operational continuity. The conceptual contribution of this report is to make visible the architecture linking these components, rather than to evaluate another isolated intervention. This single-centre experience provides a practice-based implementation framework for ageing health systems by identifying the organisational links, workforce roles, response capacities, and governance conditions required to connect otherwise isolated care components. Prospective multicentre and health economic studies are needed to assess clinical impact, scalability, cost-effectiveness, and transferability.