Institutional Innovations: Heart Failure Care Team Innovations in 2026

Health systems in Phoenix, Philadelphia, Chicago, and Cleveland are building pharmacist-run titration clinics, automatic inpatient consult triggers, and post-discharge follow-up workflows to close gaps in care for patients with heart failure with preserved ejection fraction (HFpEF) and heart failure with mildly reduced ejection fraction (HFmrEF), according to clinicians who took part in Population Health Roundtable events from The American Journal of Managed Care^® on heart failure.

Pharmacist-Run Medication Titration Clinics Reached Through a One-Click Epic Referral

Pharmacists adjust guideline-directed medical therapy (GDMT) under collaborative practice agreements (CPAs), and clinicians can refer patients with a single order to shorten the time to optimal therapy.

Penn Medicine (Philadelphia) lets clinicians send patients with heart failure to a pharmacist titration clinic through a one-click referral in Epic. Pharmacists then titrate GDMT under a CPA, which removes the need for the referring clinician to manage each dose change and gives patients who may not reach a heart failure specialist a route to optimized therapy.

Similar approaches are also underway at Temple University Hospital (Philadelphia), where an internal 3-year review, not yet published, found an average of 2.63 months to optimal GDMT; UChicago Medicine (Chicago); MetroHealth and Cleveland Clinic (Cleveland), where visits are mostly virtual; and Mayo Clinic (Arizona), where pharmacists are embedded in clinics under a CPA covering about 40 clinicians.

Epic-Embedded Inpatient GDMT Checklist

A checklist built into the electronic health record prompts inpatient teams to start and optimize GDMT before discharge.

Penn Medicine (Philadelphia) built an inpatient GDMT checklist and pathway into Epic. It currently covers heart failure with reduced ejection fraction (HFrEF) only, and clinicians described use at about 60%.

Similar approaches are also underway at Advocate Health (Chicago), which is building an interactive pathway in Epic, starting with HFrEF and still at an early stage, and Thomas Jefferson University Hospital (Philadelphia), which uses a mandatory note template.

Automatic Identification and Consult for Patients With Heart Failure on Non-Cardiology Wards

Hospitals flag patients with heart failure admitted to general medicine and other services so the heart failure team sees them without waiting for a request.

Northwestern Medicine (Chicago) uses a navigator-run patient list to find inpatients with heart failure outside cardiology and applies a standardized note, with the team seeing about 5 to 9 patients a day. The effort matters because Northwestern Medicine maintains a registry of 27,000 patients with heart failure, more than 70% of whom have HFpEF.

Similar approaches are also underway at Temple University Hospital (Philadelphia), which has a dedicated HFpEF consult order in Epic; and Rush University Medical Center (Chicago), where a report automatically places patients into an advanced practice provider (APP)–run heart failure clinic.

A Post-Discharge Follow-Up Engine for Heart Failure

A work queue, a dedicated coordinator, and automated outreach aim to get patients seen within 7 days of discharge and reduce no-shows.

Penn Medicine (Philadelphia) runs a 7-day follow-up work queue staffed by a transitions coordinator, with automated outreach campaigns through Epic. Clinicians reported that the no-show rate fell from about 50% to 25% to 30%; that figure is an internal estimate.

Similar approaches are also underway at Temple University Hospital (Philadelphia), with a 3-day call, a 7-day visit, and about 90% of patients showing up, and Banner Health (Phoenix), where a 7-to-10-day clinic has taken about 200 referrals, appointments are booked before discharge, and nurse navigators call within 48 hours.

Pharmacy-Led Inpatient GDMT Review Beyond Cardiology

Pharmacists review medications for patients with heart failure admitted to any service and send recommendations to the primary team.

Cleveland Clinic (Cleveland) runs a virtual pharmacist consult service across its Ohio hospitals. Clinicians described more than 70% of recommendations being accepted.

Similar approaches are also underway at Main Line Health (Philadelphia area), which is piloting chart notes from 2 pharmacists for all inpatients with a heart failure history; about 65% of teams were receptive, and most recommendations added a sodium-glucose cotransporter 2 (SGLT2) inhibitor.

Primary Care Pharmacists for Patients With HFpEF Not Followed by Cardiology

A pilot places pharmacists in primary care to optimize therapy for patients who never reach a cardiology clinic.

MetroHealth is piloting a primary care pharmacist program for patients with HFpEF who are not followed by cardiology. The program is at an early stage, and results are not yet available.

A related primary care approach was described at Mayo Clinic (Arizona).

Wearable Heart Failure Patch Offered at Discharge

Patients leave the hospital wearing a patch that monitors for signs of decompensation, aiming to prevent readmission.

Northwestern Medicine began offering a wearable heart failure patch at discharge in September 2025, and clinicians said about 90% of patients were covered. The same APP who leads the hospital’s pulmonary artery sensor program leads the effort. In a published open-label trial of a wearable sensor–based management system, 90-day heart failure hospitalization rates were 38% lower than in controls (HR, 0.62).¹

Rush University Medical Center (Chicago) tried the approach, but it did not take off.

AI-Drafted Prior Authorization Appeals

Clinicians use artificial intelligence (AI) tools to draft insurance appeals and cut staff time.

Mayo Clinic (Arizona) uses OpenEvidence and Copilot to draft appeals for denied medications.

A similar approach is also underway at Banner Health (Phoenix), where a medical assistant uses AI for the task.

Centralized Medication-Access Teams Open to Any Prescriber

A dedicated team handles prior authorizations and coverage for any clinician in the system, removing the burden from heart failure clinics.

MetroHealth operates a central medication-access team that serves any prescriber, including a team for glucagon-like peptide-1 (GLP-1) therapies.

Similar approaches are also underway at Penn Medicine (Philadelphia), Cleveland Clinic (Cleveland), and University Hospitals (Cleveland).

Centralized Outpatient IV Diuretic Through a Care Transitions Clinic

Patients with worsening congestion receive intravenous (IV) diuretics in an outpatient setting to avoid admission.

UChicago Medicine delivers outpatient IV diuretics through its care transitions clinic.

Similar approaches are also underway at Northwestern Medicine (Chicago), which rolled out its program recently, and Rush University Medical Center (Chicago), which delivers them in the heart failure clinic and has raised safety concerns.

Reference

Boehmer JP, Cremer S, Abo-Auda WS, et al. Impact of a novel wearable sensor on heart failure rehospitalization: an open-label concurrent-control clinical trial. JACC Heart Fail. 2024;12(12):2011-2022. doi:10.1016/j.jchf.2024.07.022