Peer-reviewed · v3.2 · February 2026

Heart failure care where there's no cardiologist.

HEARTLAND is an evidence-based implementation framework and open-source toolkit for primary care teams managing heart failure in rural and resource-limited settings across the United States. Eight modules, one shared workflow — from the first risk score to the last post-discharge call.

Read the protocol→Open the clinical app→

Built for licensed clinicians. Not a medical device. Not for direct patient care. Synthetic data only — no PHI is ever collected.

Median distance to cardiologist

87 mi

Rural counties. Urban counties: 16 miles.

Rural GDMT adherence

< 25%

on all four evidence-based classes.

The gap

The 87-mile problem.

Heart failure affects millions of Americans and is projected to nearly double in prevalence by 2050. Yet rural populations carry a disproportionate burden: higher HF incidence, higher mortality, and a median 87 miles to the nearest cardiologist versus 16 miles in urban counties. Fewer than one in four eligible rural patients receive all four guideline-directed medication classes; fewer than one percent reach target doses.

No published implementation protocol provides operational guidance for primary-care-led heart failure management in rural and resource-limited U.S. settings. GWTG-HF is a quality registry. ESC-HF-LT is European. Existing risk scores omit distance-to-care and social support despite robust prognostic evidence. HEARTLAND is the first to fill that gap.

How it works

Eight modules, one workflow.

Each module is published in the peer-reviewed protocol and operational in the clinical app. Start with one module. Add the next when you're ready.

Module 01

Risk Stratification

Existing risk scores omit rural-specific variables that independently predict HF mortality.

Jump to detail ↓

Module 02

GDMT Optimization

Fewer than 1% of rural HFrEF patients reach target doses of all four guideline-directed classes. Cost is the largest barrier.

Jump to detail ↓

Module 03

Telephone-Based Titration

Digital health assumes broadband and tech literacy. Rural communities often lack both. Titration still requires weekly contact.

Jump to detail ↓

Module 04

Discharge Transitions

Heart-failure readmission is common; structured bundles cut it — but rural patients often lack transportation to their 7-day follow-up visit.

Jump to detail ↓

Module 05

Remote Monitoring

Passive monitoring causes alarm fatigue. Active, clinician-reviewed monitoring with billing-code support is sustainable.

Jump to detail ↓

Module 06

Comorbidity Management

Heart-failure patients carry 5+ comorbidities on average. AFib, sleep apnea, iron deficiency, diabetes, CKD, COPD, and depression are near-universal.

Jump to detail ↓

Module 07

Primary Care Coordination

Communication breakdowns between hospital and PCP delay care transitions. Fuzzy referral criteria bottleneck cardiology or orphan the patient.

Jump to detail ↓

Module 08

Implementation Guidance

A 20-bed Critical Access Hospital with two nurses cannot run the same protocol as a 300-bed HF centre. Success must be tier-specific.

Jump to detail ↓

Deep dive

The protocol, module by module.

Each module opens with the clinical problem, then surfaces the two or three decisions that move the patient forward. Thresholds are clinical; links take you directly to the operational tool in the app.

Module 01

Risk Stratification

Pragmatic

Existing risk scores omit rural-specific variables that independently predict HF mortality.

HEARTLAND Risk Score (0–18): Ten variables including distance to cardiology (>50 mi) and social support (isolation). Low 0–6 / Moderate 7–12 / High 13–18.
CKM staging: Cardiovascular-Kidney-Metabolic Stage 0–4; Stage 4 associates with substantial reduction in life expectancy.
Clinical use: Supplements — does not replace — MAGGIC or SHFM. Matches monitoring intensity to individual risk.

Social isolation is associated with a 3.74× increase in heart-failure mortality. Distance >50 miles to cardiology predicts readmission. HEARTLAND captures both.

Open risk calculator→

Module 02

GDMT Optimization

Established

Fewer than 1% of rural HFrEF patients reach target doses of all four guideline-directed classes. Cost is the largest barrier.

Four pillars: ARNI (or ACE-I/ARB) + beta-blocker + MRA + SGLT2i — Class I for HFrEF per AHA/ACC/HFSA 2022.
Generic Bridge pathway: Lisinopril + metoprolol + spironolactone + dapagliflozin ≈ $15/month. No patient untreated while paperwork is pending.
Safety thresholds: K+ > 5.5 → hold MRA and ARNI. eGFR < 30 → avoid SGLT2i. ACEi→ARNI requires 36-hour washout (PARADIGM-HF).

"Generic therapy is superior to no therapy." Never delay treatment waiting for paperwork — an eligible patient on $15/month generics outlives one untreated.

Open GDMT pathway→

Module 03

Telephone-Based Titration

Established

Digital health assumes broadband and tech literacy. Rural communities often lack both. Titration still requires weekly contact.

Dual-track protocol: Track A (digital, Bluetooth, app) and Track B (voice, paper diary). Identical clinical algorithm — broadband failure never blocks care.
Cadence: Week 1 baseline call, Day 7 uptitration check, Day 14 second class introduction, then quarterly escalation over 3–6 months to target.
Hozhó Trial: Rural Navajo Nation RCT: voice telephone was the driver of GDMT success — not the app.

"Broadband failure is not a care failure." The Hozhó Trial proved a dumbphone call reaches the same clinical endpoint as a smart-home sensor.

Open titration checklist→

Module 04

Discharge Transitions

Established

Heart-failure readmission is common; structured bundles cut it — but rural patients often lack transportation to their 7-day follow-up visit.

Teach-back by tier: Tier 1: 3 core domains (daily weight, meds, warning signs). Tier 2/3: 8 domains adding sodium, fluid, activity, substances.
Bedside med delivery: Pre-packaged 7-day supply, labeled by time of day. Patient leaves the hospital with medications in hand, not a paper prescription.
48–72h call: Structured nurse call: weight delta, symptom check, adherence confirmation, any ED visit. Titrate diuretic by phone if needed.

A 68-year-old on new ARNI + beta-blocker needs three things: written + verbal teaching, a 7-day pill pack, and a Day-2 phone call asking "how many pounds?"

Open discharge bundle→

Module 05

Remote Monitoring

Established

Passive monitoring causes alarm fatigue. Active, clinician-reviewed monitoring with billing-code support is sustainable.

Human-filter principle: Every non-emergency alert passes through a licensed clinician before ED referral. Patients never self-triage to the ER on a 2-lb gain.
Basic kit ($50–150): Scale + cuff + pulse ox + paper or app diary. Blue-tooth optional — paper logs work for Track B.
Billing: CPT 99453–99458 (RPM) and 98975–98981 (RTM). Tier 2/3 facility × 20 high-risk patients ≈ $3,000–4,000/month net revenue, which offsets kit + staff.

TIM-HF2 showed the greatest mortality benefit in patients living farthest from cardiology. Human oversight beats algorithm alerts.

Open remote monitoring→

Module 06

Comorbidity Management

Established

Heart-failure patients carry 5+ comorbidities on average. AFib, sleep apnea, iron deficiency, diabetes, CKD, COPD, and depression are near-universal.

Atrial fibrillation: CHA2DS2-VASc ≥ 2 → anticoagulate. Rate control via BB; choose a cardioselective agent compatible with GDMT titration.
Sleep apnea: STOP-BANG ≥ 3 → sleep study → CPAP. Untreated OSA sabotages GDMT; CPAP improves LVEF.
Iron deficiency: Ferritin < 100 or TSAT < 20 % with Hgb < 12 → IV ferric carboxymaltose. Oral iron is poorly absorbed in splanchnic congestion.

Untreated OSA sabotages GDMT. A patient on optimal ARNI/BB/MRA/SGLT2i but with undiagnosed apnea stays symptomatic. STOP-BANG takes 2 minutes.

Open comorbidity manager→

Module 07

Primary Care Coordination

Established

Communication breakdowns between hospital and PCP delay care transitions. Fuzzy referral criteria bottleneck cardiology or orphan the patient.

SBAR handoff: One template for every discharge. Situation → Background → Assessment → Recommendation, with specific next-dose instructions.
Referral criteria: Cardiology required for EF ≤ 35 % after 3 mo optimal GDMT, recurrent hospitalization, arrhythmia, advanced-therapy consideration. Otherwise PCP-led.
Shared medical appointments: 6–8 stable HF patients + 1 provider + 1 nurse educator for 90 min. 3× throughput vs individual 30-min visits; peer accountability improves adherence.

A clear SBAR tells the PCP exactly what to do next. Without one, everyone defaults to "call cardiology" — and care stalls.

Open SBAR generator→

Module 08

Implementation Guidance

Pragmatic

A 20-bed Critical Access Hospital with two nurses cannot run the same protocol as a 300-bed HF centre. Success must be tier-specific.

Tier 1 — Critical Access Hospital: 2 RNs, paper workflows. Day-1 goals: HEARTLAND score + 2 GDMT classes at discharge + 48h call. Analog titration.
Tier 2 — FQHC / community hospital: 4–6 RNs, part-time cardiology. Full 4-pillar GDMT, digital + analog tracks, RPM kit rollout by month 3.
Tier 3 — Regional HF centre: 8–12 team members with pharmacist + social worker. Rapid-sequence GDMT; serves as hub for 3–4 satellites on the HEARTLAND framework.

"Perfect is not the enemy of good." A Tier 1 CAH starting HEARTLAND tomorrow and measuring "more patients on GDMT than yesterday" is already winning.

Open tier selector→

Scale

Three tiers for three realities.

The same protocol, calibrated to local resource. Tier 1 is "do the minimum, measure from today forward." Tier 3 trains other facilities to adopt.

Tier 1

Critical Access Hospital

1–2 RNs, 1 MD, no cardiologist on staff

Day 1: Risk score + ≥2 GDMT classes at discharge + 48h call
Month 3: Analog phone titration running weekly
Month 12: Remote monitoring with paper diary + first billing cycle

Success metric

70% of HF discharges on ≥2 GDMT classes

Tier 2

FQHC / Community Hospital

4–6 RNs, 1–2 MDs, part-time cardiology clinic

Day 1: Full 4-pillar GDMT + dual-track titration + 8-domain teach-back
Month 3: RPM kits distributed, CPT 99454 billing live
Month 12: First shared-medical-appointment cohort graduates

Success metric

85% on all 4 GDMT classes; 50% at target doses

Tier 3

Regional HF Center

8–12 team w/ pharmacist + social worker + research coord

Day 1: Rapid-sequence GDMT (days) + device evaluation ready
Month 3: Hub-and-spoke: trains 3–4 satellite primary care clinics
Month 12: Regional quality registry + outcomes publication

Success metric

95% on all 4 classes; 80% at target; <15% 30-day readmission

Adoption

From decision to first titration in 14 days.

Pick your tier. Follow the checklist. Measure from today forward.

Day	Task	Owner	Time
Day 1	Read the protocol summary (this page + Cureus abstract).	Clinical lead	20 min
Day 2	Assign a protocol champion (nurse or physician).	Leadership	5 min
Day 3	Download & laminate the HEARTLAND Risk Calculator + GDMT Quick Reference.	Nurse lead	30 min
Day 5	Train all RNs on the HEARTLAND Risk Score (15 min micro-session).	Protocol champion	1 hr
Day 7	Identify the first 3 HF patients at discharge. Calculate scores. Initiate ≥2 GDMT classes.	Clinical team	2 hr
Day 9	Make the first 48h post-discharge phone calls. Document adherence + weight.	Assigned RN	1 hr
Day 12	Debrief: how many on ≥2 classes? Any drug-cost issues? Engage the Generic Bridge pathway.	Leadership + team	30 min
Day 14	Schedule the next 3 patients for risk stratification + GDMT initiation. Plan first titration calls.	All staff	30 min

After Day 14: continue weekly titration calls. At Day 30, plan your next module (Remote Monitoring or Comorbidities). At Month 3, review % on GDMT and readmission rate, and add the next module only if the last one is running cleanly.

The ecosystem

Seven open tools for real-world use.

HEARTLAND is a coordinated set of properties, not one product. Adopt the ones that fit your workflow.

App

Clinical App

Interactive decision-support PWA with calculators, titration wizards, and alerts.

app.heartlandprotocol.org →

Scoring

Risk Engine

Zero-dependency npm package and live risk score calculator.

scoring.heartlandprotocol.org →

Guide

Pocket Guide

Offline-first bedside reference with GDMT tables and red-flag cards.

guide.heartlandprotocol.org →

Atlas

Access Atlas

County-level map of cardiology access gaps across the United States.

atlas.heartlandprotocol.org →

REDCap

REDCap Template

Pre-built REDCap instruments for the HEARTLAND registry.

redcap.heartlandprotocol.org →

Synthetic

Synthetic Cohort

Python generator for synthetic heart failure cohorts with rural variables.

synthetic.heartlandprotocol.org →

FHIR

FHIR IG

HL7 FHIR Implementation Guide for HEARTLAND interoperability.

fhir.heartlandprotocol.org →

Published

Peer-reviewed & permanently archived.

HEARTLAND v3.2 is deposited under permanent DOIs, synthesizing more than 60 clinical trials and implementation studies (2018–2025).

Cureus

Peer-reviewed manuscript

Full methods, results, discussion.

Zenodo

DOI 10.5281/zenodo.18566403

Protocol, figures, references — permanent archive.

OSF

DOI 10.17605/OSF.IO/YUSGH

Collaboration, preprints, supplementary data.

medRxiv

Preprint supplements

Validation studies linked from Zenodo.

How to cite (APA)

Ferreira VM. HEARTLAND Protocol: Heart failure evidence-based access in rural treatment, linking advanced network delivery. Zenodo. https://doi.org/10.5281/zenodo.18566403 (v3.2, February 2026).

Next step by role

Where do you come in?

Primary Care Provider

MD, DO, NP, or PA caring for heart failure patients in a rural or underserved setting.

Read: The protocol (60 min) + Module 2 (GDMT) quick-reference.
Do: Initiate ARNI + beta-blocker before your next discharge.

Open GDMT pathway→

Health-System Admin

Hospital leadership, nurse informatics, or implementation science lead.

Read: Module 8 (Implementation) + the Tier Selector quiz.
Do: Pick your tier. Assign a champion. Schedule a 15-min RN training.

Open tier selector→

Researcher

Epidemiologist, implementation scientist, biostatistician, or trainee.

Read: The full protocol in Zenodo + the REDCap instrument template.
Do: Propose a validation study. The risk score awaits prospective cohort data.

Open OSF collaboration→

Author

Vicky Muller Ferreira, MD

Independent clinical researcher. Sole author and architect of the HEARTLAND Protocol. Dedicated to extending evidence-based heart failure care to underserved rural communities across the United States.

Read

The authoritative 8-module clinical text, peer-reviewed and archived on Zenodo.

Access on Zenodo→

Adopt

Take the 1-minute tier quiz, follow the 14-day launch plan, and initiate your first patient on GDMT tomorrow.

Open the clinical app→

Cite

Use the DOI in manuscripts, grant applications, clinical notes, and policy briefs.

Copy citation from above→