WHF Roadmap for Integrated Care in People Living with – or at Risk of – Cardiovascular Disease and Multiple Long-Term Conditions

What every stakeholder should know about integrated care for CVD and MLTC

1. Integrated care is essential

   Cardiovascular disease rarely occurs alone. Most patients also live with multiple long-term conditions. Integrated care models are necessary to manage this complexity effectively, improve outcomes, and reduce the strain on health systems.

2. People-centred approaches are vital

   Integrated care puts individuals – not diseases – at the centre. Care must align with people’s needs, priorities, and capacity to manage their treatment burden. It must also include caregivers and acknowledge the support networks that contribute to health and wellbeing.

3. One size does not fit all

   Integrated models must be tailored to each context and responsive to the diverse cultural, structural, and resource-related realities that exist across – and within – countries and regions. Strategies differ according to local needs and capacities, but share a common goal: accessible, coordinated, continuous, and person-centred care.

4. The SELFIE framework provides structure

   The SELFIE framework (Sustainable intEgrated chronic care modeLs for multi- morbidity: delivery, FInancing, and performance) outlines six components – service delivery, workforce, leadership, financing, technology, and monitoring – that support integrated care implementation. However, true people-centredness requires a seventh component: partnership with patients, caregivers, and patient associations. Their co-leadership in designing and evaluating care ensures services are relevant and responsive.

5. Multidisciplinary teams are the foundation

   Effective collaboration among specialist physicians, primary care clinicians, nurses, pharmacists, community health workers (CHWs), social services, behavioural health specialists, and caregivers is essential for delivering coordinated, person-centred care. Training and support for teams must foster shared responsibility and mutual respect.

6. Digital health and data-sharing support continuity of care and personalisation

   Technology – including interoperable electronic health records (EHRs) and mobile health (mHealth) tools – enhances care coordination, enables tailored interventions, supports patient self-management, and facilitates real-time monitoring and learning.

7. Roadblocks must be addressed head-on

   Legal, governmental, organisational, cultural, and financial constraints limit progress. Resistance to change among healthcare professionals and systems remains one of the most significant obstacles. Overcoming these barriers requires leadership, investment, supportive regulation (e.g. scope-of-practice laws), education, and alignment of incentives that reward collaborative, integrated care.

8. Monitoring and evaluation (M&E) must focus on what matters most

   Evaluation should go beyond service metrics to include what matters most to people, such as quality of life, care experience, and capacity to manage one’s health. Tracking implementation, service performance, and patient-reported outcomes (PROs) ensures accountability and enables adaptation. Embedding these processes within a learning health system approach allows continuous feedback and improvement. Clear key performance indicators (KPIs) help systems learn and evolve.

9. Community involvement enhances sustainability

   High-quality health systems are people centred. Engaging patients, caregivers, and communities in the co-design, delivery, and governance of care builds trust, ensures relevance, and strengthens long-term sustainability. This inclusive approach aligns with global frameworks for effective, resilient care systems.

10. The time to act is now

    The COVID-19 pandemic exposed critical global and health system vulnerabilities, emphasising the need for integrated, adaptable care. Integrated care is not only a reform strategy, but also the foundation for building resilient, equitable, and future-ready healthcare systems able to manage rising MLTC.

1. Introduction to cardiovascular disease and multiple long-term conditions

Despite major advances in prevention, diagnosis, and treatment over recent decades, CVD and accompanying cardiometabolic conditions remain a leading cause of morbidity and mortality globally (6). Its aetiology is complex, shaped by metabolic, behavioural, genetic, social, and environmental factors. CVD is frequently interconnected with other health conditions in a bidirectional manner, with each condition worsening the other, creating a vicious cycle that intensifies disease burden (7).

At the same time, medical advances, changes in global public health dynamics, and ageing populations have contributed to a sharp rise in the number of individuals living with MLTC (8). This trend is just as evident in high-income countries (HICs) as in low- and middle-income countries (LMICs), although the nature and drivers of multimorbidity may vary locally and globally. MLTC are associated with reduced quality of life, increased healthcare costs, polypharmacy, lower treatment adherence, and clinical complexity, posing challenges for health systems regardless of income setting (5, 9, 10).

Obesity is a major contributor to MLTC worldwide (7, 11). It serves as a common driver for dysglycaemia, type 2 diabetes, atherogenic dyslipidaemia, low-grade inflammation, sleep apnoea, and suboptimal physical activity, in addition to chronic kidney and liver diseases. Obesity also worsens cardiovascular outcomes, especially in heart failure with preserved ejection fraction, atrial fibrillation, and hypertension (12).

Infectious diseases, whether acute (e.g. COVID-19, influenza) or chronic (e.g. HIV, tuberculosis, Chagas disease), can further complicate care, particularly in settings where infectious and non-communicable disease burdens coexist (13, 14, 15).

Mental health disorders, most notably depression, are common across income settings and have strong bidirectional links with CVD. Depression not only increases the risk of cardiovascular events but also undermines treatment adherence and lifestyle changes (16, 17). These challenges are compounded by social deprivation, health inequities, and systemic barriers to accessing care (18).

2. The syndemic of CVD and MLTC

Cardiovascular disease is central to the burden of multimorbidity. The Cardio-Kidney-Metabolic (CKM) syndrome, recently defined by the American Heart Association (7), encapsulates the interconnected nature of CVD, chronic kidney disease (CKD), and metabolic disorders such as obesity and type 2 diabetes (19). These conditions frequently co-occur, and their interaction accelerates disease progression and worsens outcomes.

A recent global modelling study further strengthens the syndemic framing of CVD and its interconnected risk factors. Chong et al. (20) project the global burden of CVD from 2025 to 2050, attributing it to five key modifiable risk factors: high systolic blood pressure, high LDL cholesterol, elevated fasting plasma glucose, high body mass index (BMI), and tobacco use. These risk factors – frequently co-occurring and socially determined – are not isolated epidemics but a global syndemic, collectively driving the incidence of CVD and premature mortality.

In 2050, high blood pressure alone is expected to account for 17 million deaths, with millions more from high LDL cholesterol, high fasting plasma glucose, obesity, and tobacco. Despite projected reductions in age-standardised disability-adjusted life year (DALY) rates for some risk factors, the absolute burden will remain immense due to population growth and ageing. Importantly, the authors emphasise the need for integrated, upstream prevention strategies rather than siloed risk-factor management. This supports a life-course approach, recognising that CVD and metabolic risk begins in utero and is shaped by early-life exposures, obesogenic environments and social determinants from childhood through adolescence, early adulthood and across the lifespan.

Recent research also highlights the importance of understanding how MLTC evolve over time. A large observational study by Han et al. (21) used machine learning and causal inference methods to map MLTC progression among 190 diseases in over 500,000 participants from the UK Biobank. Their findings reveal that multimorbidity is not random but tends to follow predictable patterns across disease clusters, with key chronic conditions such as CVD acting as both influencers and recipients of disease progression. Importantly, the study identifies sex-specific multimorbidity “constellations”, showing how clustering tendencies differ between males and females.

In males, progression pathways were more strongly driven by cardiometabolic conditions, with CVD occupying a particularly central role within disease networks. In females, multimorbidity patterns showed greater clustering around immune-mediated, musculoskeletal, endocrine, and mental health conditions, with more complex and interconnected trajectories over time.

These insights highlight the potential of technology-enabled, data-driven approaches to identify sex-specific disease patterns and inform cross-specialty, targeted actions for integrated care. While these associations require validation across diverse populations, mapping out these clusters is crucial to addressing the rising challenge of MLTC and developing effective, tailored interventions. Figure 1 illustrates the syndemic of living with CVD and MLTC and the need for integrated care models.

Figure 1

Managing people with CKM syndrome requires integrated, person-centred care. Clinicians treating CVD must also address conditions such as obesity, hypertension, dyslipidaemia, sleep apnoea, dysglycaemia, metabolic dysfunction-associated steatotic liver disease (MASLD), and CKD, while non-cardiovascular specialists need to evaluate and manage cardiovascular risk. Early identification of risk and coordinated, disease-modifying interventions can reduce morbidity, improve quality of life, and extend survival.

3. Burden of care

1. Definition and scope

Integrated care is increasingly recognised as a critically needed response to the rising prevalence and complexity of MLTC, particularly in people with CVD. At its core, integrated care refers to the coordinated delivery of health services that are continuous, person-centred, and responsive to the full spectrum of patient needs, across disciplines, healthcare professionals, and settings (57).

Rather than focusing on individual diseases in isolation, integrated care seeks to provide a seamless experience for patients by linking primary care, specialists (e.g. cardiologists, nephrologists, endocrinologists), mental health professionals, pharmacists, and social services within a single, coordinated framework. This approach supports more holistic, efficient, and equitable healthcare delivery (58).

Growing recognition of the overlap between cardiovascular disease and other LTCs is reflected in a recent consensus document on cardiovascular-liver-metabolic health. Chew and colleagues (59) convened a multidisciplinary panel of cardiologists, hepatologists, and endocrinologists to develop consensus recommendations on the identification and management of MASLD in people with or at risk of CVD. Their Delphi-based guidance underscores the need for earlier identification of MASLD in cardiovascular populations, and closer alignment between cardiovascular and metabolic care pathways. This work illustrates a broader shift towards evidence-informed, cross-specialty approaches to managing the multisystem consequences of cardiometabolic disease.

Integrated care encompasses:

• Multidisciplinary collaboration, ensuring all relevant professionals contribute to shared care plans.

• Continuity and personalisation of care, with ongoing follow-up and adjustments.

• Shared decision-making, recognising patient preferences and life context.

• Care coordination mechanisms, such as nurse-led teams or digital platforms.

• Proactive use of PROs to inform treatment and monitor burden (60, 61).

Despite widespread endorsement of its value, implementation remains inconsistent. As detailed in Table 1, barriers range from poor interoperability of digital systems and fragmented funding, to gaps in training, regulation, and cultural alignment across care teams (62).

2. Patient capacity and treatment burden

The growing population of people with CVD and MLTC has increasingly complex care needs. Managing multiple conditions often involves interacting with several healthcare professionals, adhering to intensive medication regimens, implementing lifestyle changes, and navigating bureaucratic or logistical obstacles. This workload is referred to as the treatment burden (60, 63).

Patient capacity, in turn, refers to personal resources available to manage this burden. These include cognitive function, health literacy, emotional resilience, physical health, financial resources, access to support networks, and digital access. When treatment burden exceeds capacity, adherence drops, complications rise, and outcomes worsen (64), as demonstrated in Figure 2.

Figure 2

As Mendoza-Quispe et al. (60) state: “Treatment burden is a key determinant of patient adherence and engagement in care, yet it is often overlooked in clinical practice and research.” Boehmer et al. (64) further emphasise the fluid nature of patient capacity, which may vary with illness episodes, stress, and changes in social circumstances.

3. Impact on outcomes

High treatment burden combined with low capacity is associated with:

• Poor medication adherence and missed follow-ups.

• Increased depression, anxiety, and disengagement from care.

• Higher risk of hospital admissions and premature death.

• Reduced quality of life and economic hardship for patients and families.

People living with CVD and MLTC face specific challenges including polypharmacy, overlapping side effects, and conflicting advice from different healthcare professionals. Common regimens may involve antihypertensives, anticoagulants, statins, glucose-lowering drugs, and other medications, each requiring careful titration, monitoring, and coordination. The WHF Roadmap on Single Pill Combination Therapies highlights that complex medication regimens and high pill burden are major barriers to adherence and effective cardiovascular prevention and management, and emphasises the importance of strategies that simplify treatment and improve coordination of care (65).

Reproduced from Pinxteren et al. (2023), Frontiers in Medicine, under CC BY 4.0 license.

As mentioned in the introduction, the WHF patient survey (see Section IV) revealed that 76% take five or more medications, yet only 9% had access to integrated risk assessment tools. Coordination of care was rated as poor or very poor by over a third (36%), while only one in five felt their care was well coordinated. This disconnect illustrates the heavy treatment burden faced by patients and the inefficiencies inherent in siloed systems.

Case study: Managing five or more prescriptions after a cardiovascular event in Brazil

Context

This case concerns a 62-year-old man living in São Paulo who was recently discharged after a non-ST elevation myocardial infarction (NSTEMI) treated with two pharmacological stents. He has type 2 diabetes (10 years), obesity, long-standing hypertension, and hyperlipidaemia. Like many patients in large urban settings, he must manage several chronic conditions at the same time. This case matters because it shows the everyday difficulties that patients face when taking multiple medicines, despite clear clinical guidelines. It highlights how complex treatment plans, overlapping dosing schedules, and worries about side effects can make it hard for individuals to maintain good long-term control of cardiovascular and metabolic risk factors.

Problem

After discharge, he was prescribed six medications: atorvastatin, metformin XR, ramipril, bisoprolol, aspirin, and clopidogrel. He frequently missed doses because he felt unsure about timing and experienced side effects. As a result, his LDL cholesterol remained high (2.4 mmol/L), blood pressure was not controlled (148/90 mmHg), and HbA1c stayed above target (8.2%). The challenge was to ensure adherence to treatment in order to meet clinical goals and reduce the risk of recurrent cardiovascular events.

Approach

The care team completed a full medication review and discussed options with the patient, including combination pills and digital reminders. They chose a “medication simplification” approach: switching to combined therapies when possible and providing clear, structured education about why each medicine was needed. His pharmacist was involved to reinforce key messages at every refill, and he joined a nurse-led cardiovascular risk clinic for regular follow-up. Other options – such as mobile phone reminders or pill-organiser systems – were considered but abandoned because he was not comfortable with digital tools. The final model aimed to reduce the complexity of his regimen, increase his understanding of his treatment, and offer consistent support from different members of the healthcare team.

Results

After three months, adherence improved from about 60% to 85% of prescribed doses. His LDL cholesterol fell from 2.4 to 1.4 mmol/L after switching to rosuvastatin/ezetimibe combination therapy. Blood pressure improved to 136/82 mmHg, and HbA1c decreased to 7.5%. Some missed doses still occurred, mostly at weekends. Structured education and pharmacist involvement were the most effective elements, while the simplified medication schedule helped but did not fully facilitate adherence.

Summary of key changes

Lessons and recommendations

Medication simplification and clear patient education are essential for improving adherence in people living with MLTC. Pharmacist involvement provides an important additional layer of support. Regular structured follow-up (such as nurse-led clinics) helps identify problems early. Digital tools may be useful but should be adapted to the patient’s abilities and preferences. Even with good interventions, perfect adherence may not be possible. Ongoing support, flexibility, and simple monitoring are key to maintaining long-term control of cholesterol, blood pressure, and diabetes.

Treatment burden also has economic implications: increased hospital use, higher system costs, and productivity losses due to work interruptions or early retirement. Reducing this burden can improve both patient outcomes and system sustainability.

Efforts to prioritise outcomes that matter most to people are particularly important in low-resource settings, where healthcare access is uneven, and out-of-pocket expenses often limit adherence. The COSMOS study, a global initiative led by Vidyasagaran et al. (66), developed core outcome sets (COS) for multimorbidity prevention and treatment trials in low- and middle-income countries. These COS – focused on treatment adherence, adverse events, out-of-pocket expenditure, and quality of life – reflect the real-world priorities of patients, caregivers, clinicians, and policymakers across 33 countries. This work reinforces the need for context-specific, person-centred outcomes in trials and health service planning, particularly for those living with the compounded burdens of CVD and MLTC in resource-constrained environments.

The POLY-HF trial (67) showed that simplifying treatment regimens can meaningfully reduce treatment burden and improve patient capacity in socioeconomically disadvantaged people with heart failure. A once daily polypill improved adherence, quality of life and improved clinical outcomes compared with usual care, with strong patient acceptability driven by reduced pill burden and fewer missed doses.

4. Global perspectives

As already mentioned, treatment burden manifests differently across settings:

• In HICs, individuals may have access to advanced care but experience fragmented services due to siloed specialties and lack of coordination.

• In LMICs, access to essential medications, diagnostics, and continuity of care is often limited. People frequently travel long distances, face high out-of-pocket costs, and may lack the digital tools or health literacy to self-manage effectively (60).

Addressing both sides of the equation – minimising unnecessary workload while strengthening patient capacity – is essential to avoid the preventable morbidity and mortality associated with poorly managed MLTC.

5. Benefits of integrated care

1. Existing integrated models

People living with CVD and MLTC often navigate highly fragmented health systems (Figure 3). These structural shortcomings have prompted the development of integrated care models, which offer a more coherent, person-centred approach to managing complex health needs.

Figure 3

Over the past two decades, numerous models have emerged in response to growing system demands and patient complexity (83). These models vary in scale, structure, and health system context, but consistently emphasise decentralisation, task-shifting, and active patient involvement (84).

Primary care-led approaches, especially in low-resource settings, can employ standardised care protocols and simplified diagnostic algorithms to manage coexisting conditions such as hypertension, diabetes, and CKD (85). For example, the HEARTS in the Americas programme in Trinidad and Tobago illustrates how primary care infrastructure, supported by tailored workforce deployment and service design, can deliver integrated CVD management (86).

As discussed in Section II.1, MASLD is common among people with cardiometabolic disease and is frequently under-recognised in cardiovascular settings, despite CVD being the leading cause of death in this population. To address this gap, an international panel led by Chew et al. developed consensus recommendations to integrate MASLD into cardiovascular care using a modified Delphi approach (87).

The guidance defines practical quality standards for integration including:

• Routine MASLD screening in high-risk cardiovascular populations.

• Incorporation of MASLD into cardiovascular risk assessment.

• Use of non-invasive tests for stratification and monitoring.

• Coordinated management across cardiology, hepatology, endocrinology, dietetics, and nursing.

This example illustrates how integrated care models can embed new diagnostic and management pathways within cardiovascular services, moving beyond single-disease silos to reduce missed opportunities for prevention and improve long-term outcomes.

2. The SELFIE framework

To guide the design and evaluation of integrated care for people with multimorbidity, including (Figure 4) CVD and metabolic conditions, the SELFIE (Sustainable intEgrated care modeLs for multi-morbidity: delivery, FInancing and performancE) framework offers a robust conceptual structure (88).

Figure 4

It outlines six core components:

1. Service delivery: ensures care is accessible, continuous, and coordinated.

2. Workforce: involves training and deploying multidisciplinary teams.

3. Leadership and governance: aligning institutional roles and policy support.

4. Financing: supporting long-term sustainability through aligned incentives.

5. Technologies and medical products: enabling care through interoperable digital tools.

6. Monitoring and evaluation: measuring outcomes to inform quality improvement.

The SELFIE framework has been successfully applied across high-, middle-, and low-income settings. In Asia, it has been used to map integrated programmes and identify key facilitators such as leadership and digital tools (89). In Europe, the framework has informed economic modelling and implementation guidance for sustainable, person-centred models.

Hospital-based heart failure clinics exemplify this approach by integrating cardiologists, nurses, diabetes educators, dietitians, and mental health professionals to deliver coordinated care and prevent readmissions. These clinics often use digital platforms for remote follow-up, self-management, and shared care planning (43).

However, a seventh component is necessary: person-centredness requires partnership with patients, caregivers, and patient associations. Their co-leadership in designing and evaluating care ensures services are relevant and responsive.

3. Key components of integrated care

Designing effective integrated care models (Figure 5) for CVD and MLTC involves a constellation of interrelated components. The International Foundation for Integrated Care identifies nine pillars that underpin effective integrated care systems (90):

1. Shared values and vision: A successful integrated care system is built on a clearly articulated and collectively supported vision that prioritises person-centred care, equity, and sustainable improvement. This shared foundation allows diverse stakeholders to align their goals and collaborate effectively.

2. Population health and local context: Care models must be responsive to the specific demographic, cultural, and epidemiological characteristics of the population. Understanding the local disease burden, health behaviours, and service access issues is essential for designing relevant and targeted interventions.

3. People as partners in health and care: Patients, families, and carers are recognised as equal partners in designing, delivering, and evaluating care. This principle supports shared decision-making, self-management, and the development of services that reflect the lived realities of service users.

4. Resilient communities and new alliances: Integrated care extends beyond the health sector, requiring collaboration with education, housing, social services, and civil society to address social determinants of health and build community capacity to support wellness and prevention.

5. Workforce capacity and capability: Health and care professionals need the right mix of skills, training, and support to work collaboratively in multidisciplinary teams. Interprofessional education, new roles such as care coordinators, and team-based service delivery are fundamental enablers.

6. System-wide governance and leadership: Strong leadership is required to guide implementation, overcome institutional silos, and maintain accountability. Governance structures should enable strategic oversight and cross-sectoral alignment.

7. Digital health: Digital solutions, such as interoperable health records, telehealth, and patient apps, facilitate information-sharing and continuity. These are essential enablers of integrated care but also raise equity and governance challenges. A more detailed discussion of digital health, including artificial intelligence (AI), is provided in Section IV.5.

8. Aligned payment systems: Financial mechanisms should incentivise collaboration, prevention, and long-term outcomes rather than episodic or volume-based care. Models such as bundled payments and shared savings are examples of alignment.

9. Transparency of progress, results, and impact: A culture of continuous improvement is driven by open reporting, robust evaluation frameworks, and the use of outcome and process indicators to measure and share results.

Figure 5

At their core, integrated care models are powered by multidisciplinary teams. Working in collaboration, they deliver holistic care that addresses both clinical and psychosocial dimensions of health. In lower-resource contexts, community health workers serve as essential contributors, delivering screening, lifestyle counselling, follow-up, and referral services. For CHWs to be effective, structured training, supervision, and access to mobile or AI-assisted tools are critical (91).

Case study: Community health worker-led hypertension screening in Kenya

Context

Non-communicable diseases are the leading cause of premature mortality worldwide, with 75% of these deaths occurring in low- and middle-income countries. In Kenya, hypertension is a major modifiable risk factor for cardiovascular disease. Many people living with hypertension also experience MLTC. National data from 2015 showed a hypertension prevalence of 25% in men and 24% in women, yet 56% of adults had never been screened. Early detection is essential to prevent CVD, but screening coverage remained low. To address this gap, the Healthy Heart Africa (HHA) programme implemented one of Kenya’s largest community-based hypertension initiatives from 2015–2018, aiming to increase screening, awareness, and linkage to care.

Problem

Nearly 90% of adults with hypertension were not receiving treatment, and more than half of Kenyans aged 18–69 had never had their blood pressure measured. The challenge was to develop a scalable approach that could expand screening reach, identify individuals with elevated blood pressure early, and link them effectively to diagnosis and treatment.

Approach

The programme trained CHWs using the Kenya Ministry of Health curriculum and deployed them to conduct both mass and opportunistic hypertension screening. At health facilities, all patients attending for any service were screened. In communities, CHWs carried out screening in households, busy public spaces, and religious institutions. Individuals with raised blood pressure were referred to a nearby facility for confirmation, diagnosis, and treatment. CHWs also followed up patients identified in the community to support linkage to care. This model was chosen because CHWs are trusted local actors, able to reach large numbers of people and provide culturally appropriate health education.

Results

Across the programme period, 663,028 blood pressure screenings were completed, with 73.9% conducted in community settings. A total of 66,981 people were started on treatment, most of whom were women (71.2%), with a median age of 55 years. While the majority of screened individuals were young adults (18–34 years), the model successfully identified large numbers of people requiring follow-up and treatment.

Lessons and recommendations

This initiative demonstrated that CHW-led screening is feasible at scale and can significantly expand access to hypertension detection.

Key lessons:

• CHWs can substantially increase reach through both community and facility-based approaches.

• Clear referral and follow-up pathways are essential to ensure linkage to treatment.

• Younger adults are frequently screened, but targeted strategies are needed to reach higher-risk groups who may be underrepresented in community campaigns.

Embedding CHW-led screening within national programmes can support sustainable hypertension control efforts.

Reference: Mbau L, Harrison R, Kizito W, Timire C, Namusonge T, Muhula S, Nyanjau L, Owiti P. Case identification, retention and blood pressure control in Kenya. Public Health Action. 2022 Jun 21;12(2):58–63. doi: 10.5588/pha.21.0051. PMID: 35734002; PMCID: PMC9176190.

Digital tools and data systems are central to enabling integration. Electronic health records, health information exchanges, and mobile health applications allow for real-time communication and monitoring. Technologies such as wearable devices, AI-supported analytics, and virtual consultations can help predict risk, enhance access, and personalise care (92, 93). Nonetheless, barriers remain. Fragmented IT infrastructure, along with regulatory and privacy concerns, can impede data-sharing. Solutions must prioritise interoperability, equitable access, and user-friendly features.

Finally, organisational and financial structures must support integration through appropriate governance, incentives, and monitoring systems (94, 95). Capitation or bundled payment models, when aligned with quality outcomes, can promote coordination and sustainability (96). Governance frameworks should include leadership structures, multidisciplinary representation, and mechanisms for feedback and continuous learning.

1. Policy and governance

Strong governance and policy frameworks create the foundation for integrated care. As discussed earlier (see Section III.3: System-wide governance and leadership), effective integration relies on shared values, strategic alignment, and collaboration across sectors. Enabling legislation can formalise multidisciplinary, team-based approaches and clarify roles and responsibilities at national, regional, and local levels.

Leadership should be multisectoral and inclusive, engaging key actors, such as health authorities, professional organisations, patient advocacy groups, and civil society. Tools such as the policy triangle – considering context, content, and actors – can help identify policy barriers and guide the development of cohesive strategies.

2. Financing and resource allocation

Financial mechanisms must support, not undermine the goals of integrated care. As outlined under aligned payment systems (Section III), traditional fee-for-service models are poorly suited to the complexity of MLTC. Alternative approaches such as bundled payments, capitation, or shared savings arrangements can incentivise coordination and continuity of care (98).

Equally important is investment in the infrastructure needed to support integrated services, particularly digital health tools and community-based delivery platforms. In LMICs, where public funding may be constrained, donor assistance and external technical support can play a catalytic role (99), but sustainability depends on resilient, locally owned financial frameworks.

3. Workforce development

A capable and supported workforce is the engine of integrated care. As noted in Section III.3, multidisciplinary teams must be equipped with the skills to collaborate across disciplines and manage people with complex needs. This requires both initial training and ongoing professional development in areas such as chronic disease management, team-based care, shared decision-making, and the use of digital tools. Examples include interprofessional rounds involving medicine, nursing, pharmacy, and social workers, mandatory primary care rotations for specialists, and continuing medical education modules on MLTC recognition or comorbidity screening.

At a system level, education and accreditation levers such as embedding MLTC competencies within medical curricula, assessments, and continuing education requirements, could help ensure that integrated care principles are consistently reinforced across the workforce.

Task-sharing is particularly relevant in resource-constrained settings. CHWs, nurse practitioners, patient navigators and care coordinators can extend the reach of integrated care when properly trained and supported. (See also Section III: CHWs and non-physician roles.)

4. Patient engagement and education

Integrated care must be co-designed with individuals and communities. Earlier we emphasised the role of patients as partners in care (Section III), highlighting shared decision-making and culturally appropriate engagement strategies. Implementation efforts should include investment in health literacy (particularly important as people increasingly encounter misleading health information online) development of multimedia self-management tools, and support for family and peer involvement. Patients should also be empowered to become advocates for better healthcare within their communities.

Importantly, systems must also create feedback loops – mechanisms for people to express needs, preferences, and experiences – which can inform service improvement and ensure care remains responsive.

5. Digital infrastructure and data systems

Digital health is a cornerstone of implementing integrated care for people with CVD and MLTC. Building on the WHF Roadmap on Digital Health in Cardiology (77), which outlined opportunities and challenges for digital transformation, this roadmap expands the perspective to multimorbidity and highlights the critical role of technology in implementation.

Beyond basic IT infrastructure, digital tools can transform care delivery, support patient engagement, and enable more equitable and person-centred models (100, 101).

Integrated EHRs, health information exchanges, and patient portals allow for continuity across healthcare professionals, providers, settings (and eventually borders, in Europe), reducing duplication and facilitating shared decision-making (45, 86). Mobile health and telemedicine extend the reach of services into communities, particularly in rural and underserved areas (102). Wearables and remote monitoring tools enable real-time tracking of symptoms, treatment adherence, and disease progression, allowing timely interventions and reducing avoidable hospitalisations (103, 104).

Artificial intelligence and advanced analytics add a further dimension. Predictive models can identify individuals at risk of deterioration, hospitalisation, or treatment non-adherence (104, 105). Natural language processing can extract relevant information from clinical records (106, 107), and AI-driven decision support can assist health workers with complex multimorbidity management (108). In resource-constrained settings, simplified mobile tools and AI-assisted training for community health workers can help bridge workforce gaps (109, 110).

However, digital transformation also brings challenges. Interoperability between systems remains limited, even in HICs (109, 111). Data privacy, ownership, and algorithmic bias raise ethical concerns (77, 112), while the “black box” nature of some AI models undermines transparency and trust. The digital divide (driven by age, literacy, socioeconomic status, and geography) risks excluding those most in need of integrated care.

To ensure safe, equitable, and sustainable adoption, countries must:

• Invest in interoperable digital infrastructure aligned with national health strategies.

• Build robust governance frameworks for data security, consent, and algorithm oversight.

• Promote inclusive design and co-creation with patients and caregivers, ensuring tools are usable and context appropriate.

• Strengthen digital literacy and workforce training, enabling clinicians, CHWs, and patients to make effective use of technology.

• Embed digital health evaluation in learning health systems (see Section VII) to monitor effectiveness, safety, and equity over time.

If implemented responsibly, digital health and AI can be powerful enablers of integrated care, improving continuity, personalisation, and efficiency while reducing treatment burden and health inequities.

6. Monitoring, evaluation, and learning health systems

Finally, the implementation of integrated care must be guided by robust monitoring and evaluation. This connects directly to the pillar of transparency and continuous improvement (Section III). M&E systems should be embedded from the beginning, with clear indicators that measure outcomes, quality, patient experience, and equity.

Adopting a learning health system approach (113) – where real-time data feeds continuous improvement – can make implementation more adaptive and evidence-driven. Transparent reporting of progress to stakeholders fosters accountability, strengthens community trust, and helps ensure that integrated care models are delivering meaningful benefits over time.

By adopting these strategic components – rooted in strong policy, sustainable financing, empowered healthcare professionals, and engaged (Figure 6) patients – health systems can build integrated models that are not only clinically effective, but equitable, resilient, and responsive to the complex realities of people living with CVD and MLTC.

Figure 6

1. Why integrated care stalls in practice: key roadblocks

Fragmentation remains the most frequently reported obstacle by both healthcare professionals and patients.

2. Key accelerators to facilitate integrated care

Key accelerators translate the principles of integrated care into practical system change by shaping how services are funded, organised, and rewarded (114).

vi. Embedded monitoring, evaluation, and learning systems

Integrated care is more likely to be sustained and scaled when monitoring and evaluation are embedded within routine practice and linked to continuous learning. The use of meaningful, person-centred and equity-sensitive indicators (beyond disease-specific metrics) allows health systems to assess whether integrated care is improving lived experience, treatment burden, continuity, and outcomes for people with CVD and MLTC (119).

Continuous feedback loops support adaptation and improvement over time, while evidence generated through learning systems strengthens accountability, informs investment decisions, and reinforces political commitment. Embedding these functions within integrated care governance creates the foundation for effective implementation and long-term impact (see Section VI).

Figure 7 is a framework that demonstrates how implementation strategies can address barriers to improve patient-level and health system-level outcomes.

Figure 7

1. High-income vs. low- and middle-income contexts

While the principles of integrated care are applicable globally, their implementation must be tailored to the realities of local health systems. As mentioned previously, HICs and LMICs face distinct structural and resource-related challenges, requiring different strategies for success (120).

In HICs, challenges often relate to system complexity and fragmentation. Care is frequently delivered through highly specialised services with limited coordination, resulting in duplicative diagnostics and inconsistent patient follow-up. Data fragmentation and siloed communication systems further hinder continuity. Common strategies to mitigate these issues include the use of shared digital health platforms, multidisciplinary case conferences, and pharmacist-led medication reviews. PROMs are increasingly used to personalise and track care over time (121).

In contrast, LMICs typically face constrained health workforces, under-resourced primary care systems, and limited access to diagnostics and specialist care (122). Weak referral networks and high out-of-pocket costs exacerbate barriers to care. Yet, innovative models based on community outreach, task-shifting to non-physician healthcare providers, and the use of mHealth tools offer promising alternatives. Community health workers play a critical role in delivering basic screening, health education, and chronic disease monitoring (123). Simplified care algorithms are used to support frontline decision-making (124).

Despite differing contexts, both HICs and LMICs benefit from strong leadership, engaged communities, adaptable models, and robust systems for performance monitoring and learning. National strategies that support decentralised planning and flexible service delivery while retaining clear quality benchmarks can be adapted to suit resource levels.

2. Community-based strategies

Community-based actions are essential to reach individuals with CVD and MLTC who might otherwise be excluded from traditional health systems. These strategies are particularly critical in LMICs and underserved regions of HICs, where access to health facilities and specialists may be limited.

CHWs, when adequately trained and supported, are instrumental in expanding the reach of integrated care (125). They can carry out screening for hypertension, diabetes, and mental health conditions; provide patient and caregiver education; and monitor medication adherence and symptom progression. To be effective, these roles must be backed by clear protocols, supervisory frameworks, and appropriate remuneration (126).

Community-based health promotion and prevention initiatives integrated into settings such as schools, faith groups, and local associations further amplify the reach and sustainability of care. Participatory approaches that include patients and caregivers in programme design foster engagement and enhance adherence.

Training is a foundational facilitator. Interprofessional education is pivotal to team-based care, while targeted instruction for CHWs and nurses ensures safe and effective task-shifting. Decision-support tools, culturally sensitive materials, and ongoing mentorship help maintain quality across diverse populations.

3. Role of digital health

Digital health tools, including mHealth, telemedicine, EHRs, and AI-driven analytics, are vital enablers across both high- and low-resource settings. Their role in bridging workforce gaps, improving coordination, and supporting self-management is transformative. Key considerations for implementation (equity, interoperability, governance, AI ethics) are discussed in detail in Section IV.5.

Implementing integrated care for CVD and MLTC requires flexibility, contextual awareness, and sustained investment (127). While HICs must overcome fragmentation and siloed care delivery, LMICs need to build systems from limited resources using community and digital innovations.

Across all settings, community-based solutions and digital tools act as vital connectors between patients and coordinated care systems. By embracing context-sensitive implementation strategies grounded in the SELFIE framework and supported by robust policy, training, and engagement, integrated care models can be scaled to meet the complex needs of diverse populations.

1. Evaluation frameworks

Structured frameworks are necessary to evaluate the multiple dimensions of integrated care.

Proctor’s implementation evaluation model (130, 131) provides a useful structure by distinguishing between:

• Implementation outcomes: adoption, fidelity, acceptability, feasibility, sustainability.

• Service outcomes: effectiveness, efficiency, safety, equity, person-centredness.

• Patient outcomes: health status, quality of life, treatment burden, satisfaction, survival.

This tripartite framing is especially relevant in MLTC because it captures not only whether services are clinically effective, but also whether they are coordinated, acceptable to both patients and professionals, and sustainable across care settings (Figure 8).

Figure 8

2. Data and measurement for integrated care

Evaluating integrated care requires linking data across conditions, healthcare professionals, patients, and settings (132). For people with MLTC, outcome measurement cannot be confined to disease-specific indicators (e.g. blood pressure or HbA1c control). It must also include:

• PROs and experience measures (PREMs), reflecting quality of life, treatment burden, and ability to self-manage across conditions.

• Cross-sectoral indicators, such as continuity between primary care, specialist services, and community support.

• Equity metrics, to ensure models benefit disadvantaged populations who are often most affected by MLTC.

High-resource systems may use electronic health records and integrated dashboards, while low-resource contexts may rely on pragmatic tools (mobile checklists, community registers) (133). In both, patient and community participation in selecting outcomes enhances relevance and trust.

3. From monitoring to learning health systems

Traditional M&E often produces static reports, but integrated care requires dynamic learning systems that provide timely insights to clinicians, managers, and policymakers (134). A learning health system continuously collects, analyses, and feeds back data to drive improvement (109).

Key elements include:

• Real-time feedback loops to frontline teams.

• Data visualisation tools for shared decision-making.

• Participatory co-design with patients and communities.

• Alignment of evaluation with planning and quality improvement cycles.

These systems are particularly important for CVD and MLTC, where treatment complexity, polypharmacy, and multimorbidity can generate unanticipated outcomes. For example, PROMs can identify where integrated care reduces treatment burden but increases complexity elsewhere, insights invisible to traditional metrics.

Case study: Using PROMs to redesign care pathways in an urban CVD + MLTC clinic

Context

This case comes from heart failure clinics at the University Health Network (UHN) in Toronto, Canada. The clinics introduced electronic PROMs, specifically the Kansas City Cardiomyopathy Questionnaire (KCCQ-12), to better understand patients’ symptoms, limitations, and quality of life. PROMs were integrated into routine care using implementation science frameworks: RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) to assess clinical integration, and the Theoretical Domains Framework (TDF) to explore behavioural factors affecting clinicians’ uptake. This evaluation reflects real-world challenges in embedding PROMs into busy, multidisciplinary services treating people with cardiovascular disease and MLTC.

Problem

Although PROMs offer valuable insight into patients’ lived experiences, their use in routine heart failure care is often inconsistent. Furthermore, HF also is associated with a higher prevalence of depressive symptoms, anxiety, and coexisting cognitive issues. The challenge was to understand how well PROMs were being adopted in the two clinics, why clinician usage varied, and what barriers and facilitators shaped sustained implementation. PROMs needed to fit into workflows without creating additional burden for staff or patients.

Approach

Heart failure patients at Toronto General and Toronto Western Hospitals were assigned KCCQ-12 questionnaires either automatically (for new patients) or manually by clinicians using prompts in the electronic record. Patients completed PROMs through MyChart, a secure digital platform. PROMs were aligned with clinic visits and limited to once every two weeks.

Clinicians – including cardiologists, internists, nurses, and nurse practitioners – were grouped by how often they assigned PROMs. Interviews with representatives from each group explored knowledge, beliefs, workflow barriers, and resource needs, guided by TDF. Clinic data were analysed to assess assignment and completion rates, patient characteristics, and trends in KCCQ-12 scores.

Results

PROM assignment and completion improved over time, reaching 80.7% completion by September 2023. Uptake was higher at Toronto General, and most completed PROMs came from male patients. Around 80% of patients consistently reported high quality of life, although a temporary decline occurred mid-year. Clinician adoption varied widely: only 11% regularly assigned PROMs, while 68% never did. Interviews identified barriers related to confidence, intention, workflow pressures, and emotional factors. Suggested strategies included targeted education, practical training, clearer workflows, and environmental prompts.

Lessons and recommendations

Sustained PROM use requires more than technical implementation.

Key lessons:

• Clear workflows and prompts support routine PROM assignment.

• Clinicians need training and reinforcement to understand how PROMs inform care.

• Behaviour-change strategies – education, modelling, environmental restructuring – can improve uptake.

• PROMs can meaningfully guide care for patients with CVD and MLTC, but adoption depends on embedding tools into everyday practice.

This evaluation shows that PROMs can be integrated into heart failure pathways and provide valuable patient insight but require ongoing support to become part of routine care.

Reference: Sarah V.C. Lawrason, Heather Ross, Michael McDonald, Juan Duero Posada, Samantha Engbers, Anne Simard, Using Implementation Science to Evaluate the Implementation of Patient-Reported Outcome Measures (PROMs) in a Clinical Heart Failure Care Setting, CJC Open, Volume 6, Issue 12, 2024. Pages 1443–1452, ISSN 2589-790X: https://doi.org/10.1016/j.cjco.2024.09.012.

4. Building capacity for sustainability

Donor-funded or pilot projects should invest in local M&E capacity so that learning systems persist beyond initial funding. This includes training health professionals in data use, standardising indicators, and fostering cultures of learning rather than compliance.

Monitoring and evaluation in integrated care for CVD and MLTC is not about proving a model works in the abstract. It is about learning what works, for whom, and under what circumstances, and using that knowledge to refine practice and policy. By embedding Proctor’s framework within a learning health system approach, health systems can ensure integrated care is not only implemented but continuously improved, equitable, and sustainable.

1. Summary of key points

The increasing prevalence of CVD related to MLTC presents one of the most significant challenges to populations and health systems worldwide. Individuals living with these overlapping conditions often face fragmented, burdensome, and inefficient care that fails to meet their complex needs. This roadmap calls for a transformative shift towards integrated care, one that is both person-centred and population health-focused, as well as equitable and responsive to the realities of both patients and health systems.

Integrated care is not simply an ideal: it is a necessity. As highlighted throughout this roadmap, CVD rarely exists in isolation. MLTC are the norm, not the exception, and addressing them through siloed, single-disease pathways is no longer tenable. Integrated care models have been shown to improve quality of life, reduce complications, enhance cost-efficiency, and strengthen the overall resilience of health systems.

This roadmap outlines actionable solutions that can be adapted across diverse settings. It presents a practical vision based on the SELFIE framework, with a focus on multidisciplinary teams, coordinated service delivery, informed use of technology, and continuous monitoring and evaluation. It also emphasises the importance of aligning governmental, legal, financial, and regulatory systems; addressing workforce and training gaps; and recognising the human cost of inaction, particularly among vulnerable populations in low-resource settings.

Equally critical is the concept of patient capacity. Integrated care must consider what people can realistically manage, not just what is medically prescribed. Without this balance, treatment burden increases, adherence declines, and outcomes worsen.

Through a combination of evidence, case examples, and implementation tools, this roadmap provides a comprehensive guide to reconfiguring care for people with CVD and MLTC. It supports healthcare professionals, policymakers, and communities in designing context-sensitive, patient-responsive systems that work.

2. A call to action

The time to act is now. Implementing integrated care to face the syndemic of CVD and MLTC requires urgency, vision, and collaboration.

Policymakers must align financing and regulatory frameworks to support integrated care models and enable task-sharing across professions. Investment in primary care, digital health infrastructure, and community-based delivery models is essential, particularly in low- and middle-income countries, where health system fragility amplifies risk.

Healthcare leaders should foster a culture of collaboration and shared accountability. This includes teamwork across disciplines, joint protocols, and robust training in both clinical and person-centred competencies. Clinicians, in turn, need to embrace interprofessional cooperation and actively include patients and caregivers in care planning.

Communities and persons with CVD and MLTC must be recognised as vital stakeholders. Their involvement in designing, monitoring, and refining care is not optional, it is foundational to making integrated care work. Patient voices offer unique insight into the lived experience of navigating chronic illness and provide a compass for improving equity, continuity, and trust.

The COVID-19 pandemic laid bare the weaknesses of health systems globally, particularly in the care of vulnerable populations with chronic conditions. As the world braces for future threats, whether from emerging infections, climate-related shocks, or demographic shifts, integrated care emerges as a critical strategy for strengthening system resilience.

Integrated care is a long-term investment in the dignity, autonomy, and wellbeing of people living with complex health needs.

3. Future directions

This roadmap is a living document. It offers not only a strategic framework for action, but also a platform for innovation, learning, and local adaptation.

Several opportunities lie ahead. Research into the effectiveness and cost-efficiency of integrated care models in varied settings is needed. Innovation in digital health, especially open-source platforms and tools for low-resource settings, can accelerate scale-up and support task-shifting. There is also a need for integrated, evidence-based guidelines for the management of CVD and MLTC, to support clinical decision-making, reduce unwarranted variation, and align care across settings and disciplines. Developing standardised care pathways and expanding health information exchange will help ensure continuity and equity.

At the same time, building learning health systems must become a core objective. These systems use real-time data and community feedback to support iterative improvement, policy refinement, and evidence-informed decision-making. As highlighted in the monitoring and evaluation chapter, strong learning systems are crucial to sustaining integrated care.

Ultimately, this roadmap envisions a future in which every person with CVD and MLTC, regardless of geography, income, social status, ethnicity and sexual orientation, receives care that is evidence-based, coordinated, continuous, and compassionate. Achieving that future requires bold decisions, smart investment, and collective commitment. But the reward can be profound: resilient healthcare systems capable of meeting today’s challenges and tomorrow’s uncertainties and, most importantly, better lives for patients, who will experience improved outcomes and more efficient and person-centred care.