COORDINATE-CVD: enhancing care transitions for older adults with complex heart disease

Professor Caleb Ferguson, University of Wollongong

Future Leader Fellowship

Years funded: 2026 - 2030

COORDINATE-CVD - a program to enhance care transitions for older adults with complex cardiovascular multimorbidity

Advances in cardiovascular medicine have led to people living longer with chronic and complex conditions. It is not uncommon for people to be living with multiple conditions: heart failure, atrial fibrillation, stroke, kidney disease and high blood pressure, to name just a few. This tsunami of predominately older adults living with multimorbidity requires innovative, interdisciplinary solutions at the level of the patient, provider and health system. This is aligned with the mission of the Heart Foundation to reduce heart disease and improve the health and quality of life of all Australians.

This fellowship project focuses on improving care for older adults with multiple cardiovascular conditions, such as heart failure, diabetes, and stroke. These patients are complex and contribute significantly to healthcare costs, but efforts to reduce hospital readmissions and improve care have had limited success. The goal is to develop sustainable strategies for coordinating care and managing these patients more effectively.

The research program aims to better understand transitional care for frail, older adults with multiple cardiovascular conditions. This will build on my existing research, including ongoing work in heart failure, atrial fibrillation, frailty, and stroke trials and translation, and the my team’s previous research on transitional care and chronic disease management.

The program will test a new intervention called 'COORDINATE-CVD', which is a nurse-coordinated, phone-based care system designed to improve outcomes for frail patients. The intervention was created using co-design methods in collaboration with Johns Hopkins University and will be adapted to fit Australia’s healthcare system. The first stage will involve adapting the intervention, followed by a large-scale trial to assess its effects on patient outcomes, such as hospital stays and survival. The final stage will explore how to make the intervention sustainable and scalable.

The fellowship aims to: 1) Test if a nurse-coordinated care program reduces hospital readmissions, death rates, and healthcare costs. 2) Generate new insights on models of care for frail older adults with heart conditions. 3) Encourage global collaboration in frailty and cardiovascular research. 4) Develop the next generation of researchers in cardio-geriatrics and frailty science.

Overall, the project seeks to improve care for frail, older adults with complex heart conditions, reduce healthcare costs, and provide new evidence for better healthcare models.

A variety of translation and dissemination strategies will be applied, including peer-reviewed publications, podcasts, animations, The Conversation news stories and policy briefs.