**4. A new model: shared care**

As the prevalence of end-stage heart disease continues to increase, the concept of "shared care" that focuses on implanting devices at a major institution and

#### **Figure 1.** *Shared-care model for LVAD patients.*

subsequently transferring follow up care to local heart failure cardiologists may expand access for LVADs to patients living in remote areas or of lower socioeconomic status who are unable to afford travel. In technical terms, a shared care LVAD center model occurs when a patient undergoes LVAD implantation at an implanting center, but greater than 50% of both the outpatient care and inpatient care alike is delivered locally [37]. This network of shared care sites can offload non-implant related issues from an implant center reducing strain on its resources while also allowing patients quicker access to routine care. In order for this to work, all care sites need to be properly trained in LVADs (**Figure 1**).

The shared-care model has been used among various specialties in medicine. In Toronto, it is being used in kidney transplant recipients with optimization of posttransplant care leading to a reduction in financial burden for patients and a reduction in follow up care volume for transplant centers [38]. They have also coordinated extensively in management of complex hematologic disorders which was initiated at Princess Margaret Cancer Centre. These models require training for community partners to ensure patient safety and satisfaction [39]. Later, it carried over to cardiology as the International Society of Heart and Lung Transplantation established guidelines for the principles of shared care after heart transplantation [40]. Now, it can be reiterated for the continuum of LVAD care.

While the model itself has been successfully implemented in complex medical conditions, it had not previously been attempted for LVAD patients. There are several examples demonstrating the success of the shared care model for LVAD patients. The Deborah Heart and Lung Center (DHLC) located in Browns Mills, New Jersey is a non-profit cardiac care specialty hospital which serves a largely underserved population in rural South Jersey. Its advanced heart failure program launched in April 2017 with partnerships and guidance from Thomas Jefferson University Hospitals, Temple University Hospital, and Robert Wood Johnson University Hospital. The shared care team consists of heart failure specialists and advanced practice providers [11]. Patients who lived in this area no longer had to travel over 90 minutes by car each way for their appointments nor did they require transfer to distant hospitals every time they were hospitalized. This allowed for all preop work-up and post-op care to
