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Context

In an effort to improve the patients’ health literacy concerning heart failure, it is important that the clinic staff and the hospital staff present a consistent, evidence-based message on self-care to these patients and their families in order to decrease acute exacerbation and re-admissions. Review current evidence for clinical practice guides or protocols when developing your patient teaching plans and materials. Consider the following:

• What does the patient know about the disease process as a baseline?
• What does the patient need to do understand as far as the best self-care processes?
• Can the patient identify proper medication compliance?
• Is there a financial issue that affects compliance?
• Who buys and prepares the food in the home?
• Can the patient verbalize when to seek medical assistance?

Questions to Consider

To deepen your understanding, you are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community.

• What factors contribute to inadequate quality of care?
• How effective are organizational mandates for quality?
• How do financial concerns impact health and safety goals?

Resources

Suggested Resources

The following optional resources are provided to support you in completing each assessment. They provide helpful information about the topics in this unit. For additional resources, refer to the Research Resources and Supplemental Resources in the left navigation menu of your courseroom.

Capella Multimedia

Click the links provided below to view the following multimedia pieces:

• Riverbend City: Insurance Issues Mission | Transcript.
• Leadership Styles | Transcript.
• Leadership, Theories, Models, and Styles | Transcript.

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Library Resources

The following resources are provided for you in the Capella University Library and are linked directly in this course. These articles contain content relevant to the topics and assessments that are the focus of this unit.

• Mensik, J. S. (2013). Nursing’s role and staffing in accountable care. Nursing Economics, 31(5), 250–253.
• Ganz, F. D., Wagner, N., & Toren, O. (2015). Nurse middle manager ethical dilemmas and moral distress. Nursing Ethics, 22(1), 43–51.
• Ott, J., & Ross, C. (2014). The journey toward shared governance: The lived experience of nurse managers and staff nurses. Journal of Nursing Management, 22(6), 761–768.
• Tait, G. R., Bates, J., LaDonna, K. A., Schulz, V. N., Strachan, P. H., McDougall, A., & Lingard, L. (2015). Adaptive practices in heart failure care teams: Implications for patient-centered care in the context of complexity. Journal of Multidisciplinary Healthcare, 8, 365–376.
• Boyde, M., Song, S., Peters, R., Turner, C., Thompson, D. R., & Stewart, S. (2013). Pilot testing of a self-care education intervention for patients with heart failure. European Journal of Cardiovascular Nursing, 12(1), 39–46.
• Brennan, E. J. (2015). Heart failure care for patients who do not speak English. British Journal of Nursing, 24(20), 1004–1008.
• Coordinating the medical home for heart failure patients; transitioning to palliative care: Adjusting locus of care and focusing on integrated medicine sheds light on best practices and patient-centered care in heart failure clinics. (2010, September 15). PR Newswire.
• Ivany, E., & While, A. (2013). Understanding the palliative care needs of heart failure patients. British Journal of Community Nursing, 18(9), 441–445.
• Limpahan, L. P., Baier, R. R., Gravenstein, S., Liebmann, O., & Gardner, R. L. (2013). Closing the loop: Best practices for cross-setting communication at ED discharge. American Journal of Emergency Medicine, 31(9), 1297–1301.
• Lingle, C. L. (2013). Evidence based practice: Patient discharge education barriers to patient education (Master’s thesis). Available from ProQuest Dissertation Publishing. (UMI No. 1542582)
• Delaney, C., Apostolidis, B., Bartos, S., Morrison, H., Smith, L., & Fortinsky, R. (2013). A randomized trial of telemonitoring and self-care education in heart failure patients following home care discharge. Home Health Care Management and Practice, 25(5), 187–195.
• Wolfson, B. J., & Campbell, R. (2014, February 9). With Medicare watching, hospitals make changes: Orange County medical centers put new focus on discharge practices to reduce patient readmissions. Orange County Register.
• Berry, L. L., Rock, B. L., Houskamp, B. S., Brueggeman, J., & Tucker, L. (2013). Care coordination for patients with complex health profiles in inpatient and outpatient settings. Mayo Clinic Proceedings, 88(2), 184–194.
• Veenstra, W., op den Buijs, J., Pauws, S., Westerterp, M., & Nagelsmit, M. (2015). Clinical effects of an optimised care program with telehealth in heart failure patients in a community hospital in the Netherlands. Netherlands Heart Journal, 23(6), 334–340.
• Aller, M., Vargas, I., Coderch, J., Calero, S., Cots, F., Abizanda, M., … Vázquez, M. L. (2015). Development and testing of indicators to measure coordination of clinical information and management across levels of care. BMC Health Services Research, 15(323), 1–16.

Course Library Guide

A Capella University library guide has been created specifically for your use in this course. You are encouraged to refer to the resources in the BSN-FP4012 – Nursing Leadership and Management Library Guide to help direct your research.

Internet Resources

• National Council of State Boards of Nursing (NCSBN). (n.d.). Retrieved from https://www.ncsbn.org/index.htm
• American Nurses Association (ANA). (2015). Code of ethics for nurses. Retrieved from http://www.nursingworld.org/MainMenuCategories/Eth…

Bookstore Resources

The resources listed below are relevant to the topics and assessments in this course. Unless noted otherwise, these materials are available for purchase from the Capella University Bookstore. When searching the bookstore, be sure to look for the Course ID with the specific –FP (FlexPath) course designation.

• Kelly, P., & Tazbir, J. (2014). Essentials of nursing leadership and management (3rd ed.). Clifton Park, NY: Delmar.
  • Chapter 2.
  • Chapters 11–15.

Assessment Instructions

Preparation

Refer to the Capella library and the Internet for supplemental resources to help you complete this assessment.

Instructions

Deliverable: Develop an evidence-based plan for health care delivery.Scenario:The hospital where you work has an issue with increased readmissions within 30 days of discharge. After examining the core measures, it was found that heart failure was the most common core measure disease process experiencing the highest rate of readmissions. The leadership team has given your team the charge of developing a nurse-run outpatient heart failure clinic. The purpose of this clinic is to ensure that discharge education is presented to the patient in an orderly, consistent manner and complies with evidence-based practice protocols. Since these patients may be discharged from a variety of areas in the facility, having the heart failure clinic staff take ownership of the process will improve both consistency and compliance. There are cardiologists that interact with the staff and patients, but the day-to-day operations of the clinic are designed and supported by the nurses as they interact with appropriate members of the other health care team disciplines promoting the best care for the heart failure patients.As a member of the nurse team, you have been asked to develop one component of the clinic.The hospital leadership established these objectives for the clinic services:

• Evaluate and maximize proper medication therapy.
• Conduct regular diet, exercise, and stress management classes for the patients.
• Monitor physiological indicators for the patients (lab work, weights, vital signs, ECGs).
• Provide a case management system for patients in the program post-discharge.

The overall goals for the heart failure clinic are to:

• Enroll greater than 90 percent of the patients with a primary or secondary diagnosis of HF prior to discharge.
• Facilitate discharge planning to achieve 100 percent compliance with patient education prior to discharge (discharge planning).
• Decrease readmission rates in this population by 5 percent over the next year.

The leadership team has asked you to provide them with an evidence-based plan for one of the components of the clinic. You may use any combination of documents (for example, a spreadsheet or a table) in addition to explanatory information to convey information clearly and succinctly.Develop one: an Orientation Course Plan, a Discharge Education Plan, or a Care Coordination Plan.An Orientation Course Plan:

• Develop an evidence-based plan for health care delivery.
• Include a comprehensive schedule of topics, objectives, key points, and patient resources for the orientation course.
  • What are the components of an evidence-based education plan?
  • How will you know that patients will understand what to do?
  • What modalities will you use to deliver information?
  • How will you adapt the plan to meet the needs of patients from diverse cultural and language backgrounds?
  • Identify specialized and supplementary material needs.

• Apply professional and legal standards in support of a care plan.
  • Explain the alignment to the most recent Heart Failure Guidelines and specific professional standards.
  • Describe the accountability tools and procedures used to measure effectiveness.
  • How will you know if the patient education plan is successful?
  • What are the indicators of success or effectiveness?

A Discharge Education Plan:

• Develop an evidence-based plan for health care delivery.
  • Develop a discharge plan with objectives and resources, and tools for patients to monitor their progress.
  • How will you know that patients understand what to do?
  • What modalities will you use to deliver information?
  • How will you adapt the plan to meet the needs of patients from diverse cultural and language backgrounds?
• Apply professional and legal standards in support of a care plan.
  • Explain the alignment to the most recent Heart Failure Guidelines and specific professional standards.
  • Describe accountability tools and procedures used to measure effectiveness.
  • How will you know if the discharge plan is successful?
  • What are the indicators of success or effectiveness?

Care Coordination Plan:

• Develop an evidence-based plan for health care delivery.
  • Develop a procedure for coordinating services.
    • Consider the needs of “outliers.” For example, someone with lung disease may need extra resources.
    • Who should be on the team?
    • When would the team be activated?
    • How would it be activated?
    • What is the time frame required to coordinate services?
    • How would the intervention plan be monitored for effectiveness?
• Apply professional standards in support of a care plan.
  • Explain the alignment to the most recent heart failure guidelines and specific professional standards.
  • Describe accountability tools and procedures used to measure effectiveness.
    • How will you know if the care coordination plan is successful?
    • What are the indicators of success or effectiveness?
    • How will information be collected or communicated?

Additional Requirements

• Written communication: Written communication should be free of errors that detract from the overall message.
• APA formatting: Resources and in-text citations should be formatted according to current APA style and formatting.
• Length: The report should be 3-4 pages in content length, double-spaced.
• Font and font size: Times New Roman, 12 point.
• Number of resources: Support your plan with a minimum of three peer-reviewed resources, in addition to professional standards.