HEARTLAND Facility Implementation Tier: Tier 2 - Standard

HEARTLAND Monitoring Track Assignment: Analog Track B

status: Active

intent: Plan

subject: Rural Patient Example Female, DoB: 1947-06-15 ( https://fhir.heartlandprotocol.org/sid/example-mrn#EXAMPLE-001)

period: 2026-04-16 --> 2026-07-16

activity

Details

-	Status	Scheduled[x]	Description
*	Not Started	Uma vez	Initiate all 4 GDMT classes (ARNI/ACEi/ARB, beta-blocker, MRA, SGLT2i) within 14 days per Tier 2 protocol. Prioritize SGLT2i and beta-blocker first if simultaneous initiation not feasible.

activity

Details

-	Status	Scheduled[x]	Description
*	Scheduled	Uma vez	Post-discharge contact within 48 hours by RN champion.

activity

Details

-	Status	Description
*	Scheduled	7-day in-person follow-up visit at FQHC for vitals, medication reconciliation, and GDMT titration.

activity

Details

-	Status	Scheduled[x]	Description
*	Scheduled	Contagem 4 times, Uma vez por 1 week	Weekly follow-up phone calls x 4 weeks (Track B analog) capturing weight, blood pressure, oxygen saturation, and symptom assessment.

activity

Details

-	Status	Description
*	Scheduled	Full discharge teach-back covering 8 AHA-aligned domains: (1) daily weight monitoring, (2) sodium and fluid restriction (<=2 g/day Na, 1.5-2 L fluid), (3) medication adherence and timing, (4) symptom recognition (red flags), (5) activity and exercise progression, (6) when to call provider vs ED, (7) follow-up appointment plan, (8) self-care between visits.

activity

Details

-	Status	Description
*	Scheduled	Patient assistance program (PAP) pursuit + Generic Bridge for medication access. Generic therapy is superior to no therapy; never delay treatment while waiting for paperwork.

note:

Tier 2 protocol: full implementation over 12 months with phased rollout. Quality metrics: dose optimization and 30-day readmission reduction.