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

TL;DR

This paper presents a global roadmap for improving care for people with cardiovascular disease and multiple long-term health conditions.

Contribution

The roadmap offers a structured framework for implementing person-centered, coordinated care models globally.

Findings

Fragmented care models are ineffective for managing multiple long-term conditions alongside cardiovascular disease.

Integrated care strategies can improve outcomes and reduce healthcare costs in diverse income settings.

Multidisciplinary teamwork and digital health are emphasized as key components of effective care.

Abstract

Cardiovascular disease (CVD) commonly coexists with multiple long-term conditions (MLTC), including diabetes, chronic kidney disease, obesity, and mental health disorders. This clustering creates a syndemic burden associated with poorer outcomes, polypharmacy, high treatment burden, and rising healthcare costs. Fragmented, single-disease care models are ill-suited to address this complexity.

The WHF roadmap for integrated care in people living with – or at risk of – CVD and MLTC provides a structured framework to support the design, implementation, and scale-up of person-centred, coordinated care models globally. Drawing on current evidence, expert consensus, case studies, and stakeholder surveys, the Roadmap outlines the epidemiological and systemic challenges of MLTC and identifies practical strategies adaptable across high-, middle-, and low-income settings.

This Roadmap emphasises multidisciplinary teamwork, aligned financing, digital health infrastructure, workforce development, patient partnership, and robust monitoring and evaluation. By shifting from siloed care to integrated, capacity-sensitive approaches, health systems can improve clinical outcomes, enhance quality of life, reduce avoidable hospitalisations, and build resilience in the face of growing multimorbidity.

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