Coordinated Care for Frail Patients With Heart Failure

This trial is testing a new coordinated care approach for older adults who are frail and have been hospitalized with heart failure. Instead of receiving care only from individual doctors, participants will work with an interdisciplinary team — including hospital doctors, nurses, and community care providers — who create a personalized treatment plan together. The goal is to improve your symptoms, quality of life, and how often you need hospital care.

Frail older adults with heart failure are often left out of treatment studies, even though they have the most to gain from better care coordination. This trial exists because guidelines are calling for research that directly addresses how to help this vulnerable group manage their condition and maintain their independence.