Five categorical items derived from HEARTLAND Protocol v3.2 Table 2 to support facility self-assessment for implementation tier assignment (Tier 1 Minimal / Tier 2 Standard / Tier 3 Advanced). Items cover staffing model, PharmD availability, CHW program, monitoring technology, and financial navigation capacity. Tier assignment is qualitative: predominance of 'minimal' answers maps to Tier 1; 'standard' to Tier 2; 'advanced' to Tier 3. This is an operational instrument derived from Table 2; the source protocol does not provide a formal scored tool.

Three boolean items derived from HEARTLAND Protocol v3.2 Table 4 (Track Assignment Form) to determine whether a patient should be enrolled in Track A (digital, app-based) or Track B (analog, telephone) remote monitoring. Decision logic: smartphone with reliable connectivity AND comfortable using apps -> Track A; reliable telephone access only -> Track B; smartphone without app comfort -> Hybrid. Both tracks follow identical clinical algorithms per Module 3.

Captures the 10 binary inputs to the HEARTLAND Protocol v3.2 risk score. Each item carries an itemWeight extension with its point contribution. Total score (0-18) maps to qualitative tiers: low (0-4), moderate (5-8), high (>=9). Item text is verbatim from manuscript/tables.R Table 1 (HEARTLAND v3.2).

Heart failure care plan structured per HEARTLAND Protocol v3.2. Activities are organized around five domains: GDMT initiation/titration, remote monitoring schedule, post-discharge follow-up (calls and visits), discharge education (3 condensed or 8 comprehensive domains), and patient assistance navigation. Two extensions identify the facility implementation tier and the assigned monitoring track (A digital / B analog).

Patient profile carrying HEARTLAND-specific extensions used by the risk score: distance to cardiology and social support status. Constrains the base FHIR R4 Patient resource for use within HEARTLAND Protocol v3.2 workflows.

Captures responses to any HEARTLAND-defined Questionnaire (risk inputs, facility tier self-assessment, or patient track assignment). Used as the basis reference for HeartlandRiskAssessment when the questionnaire is HeartlandRiskInputQuestionnaire.

Observation captured via the HEARTLAND remote monitoring kit (Module 5): body weight, blood pressure (systolic/diastolic), or oxygen saturation. Red-flag thresholds are encoded via Observation.referenceRange with meaning.text identifying the rule. Default thresholds (HEARTLAND v3.2 standard, configurable per program): weight gain >=2 lb (0.9 kg)/24h or >=5 lb (2.3 kg)/7d; SBP <90 or >180 mmHg; DBP <50 or >110 mmHg; SpO2 <90% on room air. Per the human filter principle, all non-emergency alerts pass through licensed clinician telephone assessment before ED referral.

Heart failure risk stratification per the HEARTLAND Protocol v3.2 risk score. The score sums up to 18 points across 10 binary inputs and maps to three qualitative tiers: low (0-4), moderate (5-8), high (>=9). The basis SHALL reference a HeartlandRiskInputQuestionnaire QuestionnaireResponse capturing the 10 input variables.

Driving distance in miles from the patient's residence to the nearest cardiologist. Used by the HEARTLAND risk score: distance >50 miles contributes 1 point. Rural counties without a cardiologist average 87 miles to nearest cardiology care vs 16 miles in counties with one (HEARTLAND Protocol v3.2, Module 2).

Identifies the HEARTLAND Protocol v3.2 implementation tier (1 Minimal, 2 Standard, 3 Advanced) at which a facility, organization, or care plan operates. Drives which protocol activities (monitoring, GDMT cadence, education, follow-up) are operationally feasible.

Assigns a CarePlan to either Track A (digital, app-based) or Track B (analog, telephone/paper) per HEARTLAND Protocol v3.2 Module 5. Both tracks follow identical clinical algorithms; the choice reflects patient access to technology and facility implementation tier.

Boolean indicator of limited social support per the HEARTLAND risk score: true = patient lives alone or has limited social support, contributing 1 point. Perceived social isolation has been independently associated with a 3.74-fold increase in mortality among HF patients (HEARTLAND Protocol v3.2, Module 2).

LOINC codes for the four observations captured by the HEARTLAND remote monitoring kit per Module 5: body weight (digital scale), systolic and diastolic blood pressure (BP monitor), and oxygen saturation (pulse oximeter, when indicated).

Three-tiered transparency labels distinguishing evidence strength behind HEARTLAND Protocol v3.2 recommendations, helping clinicians calibrate clinical decisions.

Facility implementation tiers from HEARTLAND Protocol v3.2 Module 8. Tiers reflect available resources (staffing, technology, financial navigation) and dictate which protocol components are operationally feasible at a given site.

Patient-level remote monitoring track assignment from HEARTLAND Protocol v3.2 Module 5. Both tracks follow identical clinical algorithms, differing only in data collection method.

Qualitative risk stratification tiers from the HEARTLAND Protocol v3.2 risk score (0-18 points). Used in HeartlandRiskAssessment.prediction.qualitativeRisk.

Body weight observation for PatientExampleRural captured via Track B (telephone-reported) showing a +1.2 kg gain in 24 hours. Reference range encodes the HEARTLAND default red-flag threshold (>=0.9 kg in 24 hours triggers clinician outreach per the human filter principle).

Risk assessment for PatientExampleRural scoring 11/18 points (>=9 = High Risk tier). Inputs: age >=75 (+2), prior HF hosp 6mo (+3), eGFR <45 (+2), BP <100 (+2), distance >50 mi (+1), limited social support (+1). Triggers Intensive Bundle per HEARTLAND v3.2.

Responses to the HeartlandRiskInputQuestionnaire for PatientExampleRural. Six items answered true (age >=75, prior HF hosp 6mo, SBP <100, CKM Stage 3-4, distance >50 mi, limited social support) totaling 11 points -> High Risk tier. Referenced by RiskAssessmentExampleHigh.basis[0].

A 78-year-old patient living alone in a rural county without a local cardiologist (87 miles to nearest cardiology care). Demonstrates use of HeartlandDistanceToCardiology and HeartlandSocialSupportScore extensions. Modeled on the cohort described in HEARTLAND Protocol v3.2 background data.

Care plan for PatientExampleRural at a Tier 2 (Standard) FQHC. Patient was assigned Track B (analog) because rural broadband is unreliable. Plan includes target initiation of all 4 GDMT classes within 14 days, weekly follow-up calls for 4 weeks, 7-day in-person visit, and full 8-domain teach-back education.