Background <p>Older adults with chronic health conditions like heart failure (HF) and cognitive impairment face challenges managing complex medication regimens, leading to poor adherence, worsening clinical status, and increased healthcare costs. Many existing interventions to improve medication adherence depend on digital technologies that may be too complex or require consistent caregiver support limiting their effectiveness in this population. Prior research demonstrated the efficacy of a simple pictorial medication sheet intervention compared to usual care. This study evaluates the cost-effectiveness of a pictorial medication sheet compared to usual care for older adults with HF and cognitive impairment.</p> Methods <p>We developed a decision tree model with disease states in Microsoft Excel to evaluate changes in costs and quality-adjusted life years (QALYs) after implementing the intervention for older adults living with cognitive impairment and HF. The base case model used a one-year time horizon with adherence pathways and clinical outcomes, including decompensation, recovery, worsened or stable HF, and death. QALYs were calculated based on survival pathways and changes in health state utility. Costs included the intervention’s implementation and direct medical expenses related to HF care in the US. Sensitivity analyses (one-way, scenario, and Monte Carlo) explored how uncertainty in parameter inputs and time frame affects results.</p> Results <p>Over a one-year time horizon, our model showed individuals using the pictorial medication sheet intervention had a total cost of $22,557 and 0.691 QALYs. Compared to usual care, the intervention was dominant (less costly and more effective), with $1,949 lower cost and a gain of 0.0045 QALYs, thus implementation for 100 individuals would potentially yield 0.45 QALYs and save $195,000 annually. Sensitivity analyses found that the intervention remained dominant over one year across plausible parameter ranges. A two-year analysis found that the intervention remained dominant across all tested scenarios, with QALY gains increasing almost six times more than the one-year model and cost savings ranged from $2,279 to $4,497 per patient.</p> Conclusions <p>The pictorial medication sheet appeared to be cost saving and more effective than usual care for older adults living with cognitive impairment and HF in the United States. This finding supports evaluating strategies to implement the pictorial medication sheet at scale.</p> Clinical trial number <p>Not applicable.</p>