Effects of a Multidisciplinary Integrated Care Model on Care Outcomes in Patients With Heart Failure With Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous clinical syndrome characterized by signs and symptoms of heart failure with a left ventricular ejection fraction ≥50%. It disproportionately affects older adults and patients with multiple comorbidities, including hypertension, diabetes, obesity, and chronic kidney disease. Despite its high prevalence and disease burden, few pharmacologic therapies have demonstrated consistent benefit in this population, highlighting the importance of non-pharmacologic and system-level interventions.

This study investigates whether a Multidisciplinary Integrated Care Model (MICM) improves care outcomes for patients with HFpEF compared with historical usual care. The MICM intervention integrates the following components:

• Cardiology-led clinical management with guideline-directed medical therapy optimization
• Case management for care coordination, symptom monitoring, and care transitions
• Pharmacist-led medication review and adherence support
• Nutritional counseling tailored to heart failure and comorbidity management
• Structured exercise and cardiac rehabilitation guidance
• Patient and caregiver education on self-management and warning signs

Eligible participants are adults diagnosed with HFpEF (left ventricular ejection fraction ≥50%) who receive care at the study institution. The intervention cohort will be prospectively enrolled and followed under the MICM program, while the historical control cohort will consist of patients who received standard usual care prior to program implementation, matched on relevant baseline characteristics.

Outcomes of interest include heart failure-related hospitalization and emergency visits, all-cause mortality, functional capacity, NYHA functional class, and health-related quality of life. Data will be collected through structured clinical assessments and medical record review at baseline and at scheduled follow-up intervals.

Findings from this study are intended to generate evidence on the effectiveness of multidisciplinary, team-based care models in improving outcomes for patients with HFpEF, and to inform future integrated care program development in similar clinical settings.

Inclusion criteria

• Age 18 years or older
• Hospitalized with a physician diagnosis of heart failure with preserved ejection fraction (HFpEF)
• Left ventricular ejection fraction (LVEF) ≥50% on echocardiography performed during the index hospitalization
• New York Heart Association (NYHA) functional class III to IV
• Able to communicate in Mandarin or Taiwanese and understand the study intervention
• For the prospective intervention group: willing to participate and provide written informed consent. For the historical control group: existing medical record data will be collected under a waiver of informed consent.

Exclusion criteria

• Patients who elected hospice or palliative care as part of an advance care plan during the index hospitalization
• Severe cognitive impairment without a family member or caregiver available to assist with the digital platform
• Anticipated inability to complete post-discharge follow-up or lack of regular follow-up at the study institution's outpatient clinic
• Length of index hospital stay less than 24 hours