Table 2.

Key therapeutic targets and their evaluation

Therapeutic target	Key interventions	Primary evaluation
Optimize individual factors to promote safe and effective self‐management	Home assessment of individual awareness and social circumstances at 7–14 days	Health‐related quality of life
	Referral to social worker	Mental health status
	Individual targets negotiated	Self‐care status (knowledge and adherence)
Optimize cardiovascular risk profile	Comprehensive risk profiling at 30 day clinic	Absolute cardiovascular risk assessment (primary and secondary)
	Comprehensive reports to GP and specialists	Change in body fatness, blood pressure, lipid profile, and smoking status
	Coaching to individualized targets
	Develop chronic disease management plan
	Annual NIL‐CHF clinic
Optimize clinical management of pre‐existing diabetes and CVD	Treatment review relative to clinical diagnoses and supplementary clinical profiling (NIL‐CHF clinic)	Adherence to gold‐standard guidelines for pharmacological and non‐pharmacological management
	Referral to home pharmacy reviews and management	Cardiac function (e.g. presence/absence of left ventricular hypertrophy and systolic and diastolic function)
Referral to specialist services (e.g. diabetes clinic, social workers, and dieticians)
	Annual NIL‐CHF clinic
Optimize clinical management of potentially related co‐morbidity	Assessment of renal function, carotid intima‐medial thickness, ankle‐brachial index	Adherence to gold‐standard guidelines for pharmacological and non‐pharmacological management
	Comprehensive reports to GP and specialists	Renal function
	Referral to specialist services (e.g. renal and vascular clinics)	Carotid intima‐medial thickness
		Ankle brachial index
		Cognitive status
Prevent progression to CHF or a fatal event	Combination of all of the above during study follow‐up (3–5 years)	Primary composite endpoint
		Multivariate analyses of independent correlates of event‐free survival
		Cardiovascular‐specific and all‐cause hospital events and stay