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