Advanced Practice Nurse–Led Cardiogeriatric Heart Failure Pathways: A Narrative, Practice-Based Description of an Integrated Care Model

Abstract

Aim: To describe and conceptually examine a nursing-led cardiogeriatric heart failure (HF) pathway in which Advanced Practice Nurses (APNs) assume expanded clinical and organisational leadership roles. Background: HF predominantly affects older adults and is frequently associated with frailty, multimorbidity, and reduced physiological reserve. Conventional hospital-centred models often expose frail older patients to functional decline and iatrogenic harm, highlighting the need for integrated, outpatient-oriented care pathways. Design: Descriptive, narrative, and conceptual practice-based innovation report. Methods: This paper reports the development and implementation of an APN-led cardiogeriatric HF pathway at Hôpital La Porte Verte. The model integrates day hospital interventions, medication titration, therapeutic education, telemonitoring, and interprofessional coordination. No formal quantitative evaluation, comparative analysis, or systematic literature review was conducted. Results: The pathway illustrates how APNs can operate beyond traditional supportive roles, assuming advanced clinical decision-making, risk management, and organisational leadership in the care of frail older adults with HF. The model supports continuity of care, patient and caregiver empowerment, and safer management of complex clinical situations. Conclusion: This innovative approach contributes to the understanding of APN roles in cardiogeriatric HF care. It highlights the potential of APNs as frontline clinical leaders in integrated care models and provides a potentially transferable framework to inform future nursing practice, leadership, and research. This descriptive, practice-based report is intended to inform real-world practice and support the transferability of APN-led integrated care models across healthcare systems.