Disseminating the Evidence Scholarly Video Media Submission
Greetings! Everyone. My name is ____, and in this video, I will discuss how to enhance care coordination for Chronic Heart Failure (CHF) patients through the execution of practical intervention. CHF is a prevalent disorder, affecting more than 6 million people in the United States (US) (Khan et al., 2020). In this video, I will explore the challenges associated with coordinating care to meet the clinical preferences outlined in the developed PICOT question. Additionally, I will emphasize resources that foster cross-disciplinary collaboration to enhance the well-being of CHF patients and outline strategies for engaging stakeholders.
Analysis of Care Coordination Efforts related to PICOT Question
The PICOT query addressed is given below:
“In adults with CHF in an ambulatory care setting (P), does the employment of a nurse-led intermediate care management program (I), compared to typical discharge (C), decrease 30-day hospital readmissions (O) in three months post-discharge (T)?”
CHF patients require collaborative care within ambulatory settings for effective management. High hospital readmission rates for CHF patients due to inadequate post-discharge care have been identified as a critical issue that delays care coordination. This fragmented care delivery leads to increased 30-day hospital readmissions, healthcare costs, worsened patient outcomes, straining healthcare resources, and compromising patient well-being (Li et al., 2021). There is a pressing demand for implementing nurse-led transitional care management programs that provide personalized care plans for CHF patients, regular follow-ups, and enhanced education for the interprofessional healthcare team. This approach can facilitate smooth communication and coordination through complete discharge planning and personalized CHF patient education (Li et al., 2021). Additionally, integrating care coordination with Electronic Health Records (EHR) can facilitate communication and track patient progress.
Practical steps involve establishing structured protocols for patient transitions, leveraging telehealth for continuous monitoring, and ensuring thorough medication reconciliation. Moreover, medical staff can utilize a centralized electronic system to access real-time patient information and receive alerts about changes in a CHF patient’s condition, ensuring the entire team stays informed (Samal et al., 2021). By focusing on these areas, the program addresses gaps in post-discharge care, improves adherence, and reduces readmission rates, aligning with best practices for managing CHF in adults. The EHR offers extensive patient health information, which healthcare management and quality control departments examine to detect patterns. It ensures all stakeholders understand the importance of enhancing care coordination to enhance well-being and decrease readmissions of CHF patients. This information-based approach improves the capability to arrange and manage clinical needs more efficiently (Samal et al., 2021).
Key Implications and Conclusions
Executing a nurse-led transitional care management program within an ambulatory care setting enhances care coordination for CHF patients. This approach involves assessing patient needs, personalized care plans, and collaborating with the interdisciplinary team, including cardiologists, nurses, and dietitians. Key components include patient education, medication management, symptom monitoring, and adherence to structured communication protocols (Chestnut et al., 2021). By aligning with care coordination standards, this program aims to reduce hospital readmissions and improve CHF patient self-management. Regular evaluations and adjustments are crucial for maintaining effective care and achieving optimal results. To boost outcomes, the program emphasizes enhanced interprofessional collaboration, structured communication, and routine team meetings to prevent fragmented care. It features standardized discharge instructions, telehealth monitoring, and medication reconciliation. Additionally, integrating EHR facilitates seamless communication, real-time updates, and a comprehensive view of patient care. This strategic approach aims to advance healthcare services for CHF patients (Li, Fu, et al., 2021).
Modifications in Practice and Resources for the Interprofessional Care Coordination Team
A nurse-led intermediate care management program is the most effective strategy for enhancing evidence-based care for CHF patients. This approach, which includes thorough discharge planning, personalized patient education, and consistent follow-up, benefits interprofessional care teams, including cardiologists, nurses, dietitians, and pharmacists. Regular evaluations and feedback from both patients and providers are crucial for refining practices and boosting patient satisfaction. The “Patient-Centered Care” model supports continuous feedback, improving care coordination and health outcomes for CHF patients (Ledwin & Lorenz, 2021).
Furthermore, leveraging a comprehensive EHR system offers a single platform where multidisciplinary care team members can access current patient information. This system addresses post-discharge care gaps, enhances adherence, and reduces readmission rates, aligning with best practices for CHF management. The effectiveness of shared EHR systems relies on their seamless integration and accurate data entry (Sokan et al., 2022). Patient engagement and adherence to educational and treatment plans require continuous training and support for healthcare specialists, along with strategies to actively engage patients. The nurse-driven initiative promotes cooperative care planning and enables team members to participate in and access a cohesive care plan, a significant improvement over traditional practices missing telehealth integration (Sokan et al., 2022).
The shift to a nurse-driven transitional care management program is motivated by the demand for more effective, patient-focused care management. Research-based on evidence indicates that improved access to CHF patient data through EHR results in improved health outcomes and more effective CHF management (Samal et al., 2021). The nurse-led transitional care program addresses critical aspects such as discharge planning, patient education, and follow-up care, reducing complications and hospital readmissions. For example, the Heart Failure Transitional Care Program at the Cleveland Clinic demonstrates these principles, ensuring equitable, high-quality care that honours individual patient needs (Raat et al., 2021).
Strategies to Enhance Stakeholder Engagement in the Interprofessional Team
The involvement of key participants in multidisciplinary teams is crucial for the successful execution of a nurse-led care plan in ambulatory settings. Effective leadership is critical to overcoming uncertainties and ensuring active participation from all stakeholders (Kirakalaprathapan & Oremus, 2022). In this setting, the appropriate investors are cardiologists, nurses, dietitians, managerial staff, IT professionals, and care staff. To foster strong shareholder involvement, nurses can organize interprofessional meetings to explain each member’s role in improving care for adult CHF patients through the collaborative use of the nurse-led transitional care management program. This approach enhanced stakeholder commitment and led to the creation of targeted interprofessional care plans utilizing telehealth platforms for discharge planning, patient education, and follow-up care. It helped reduce complications and hospital readmissions (Li et al., 2021). Additionally, specialized support from IT specialists was provided during the EHR implementation to address immediate concerns. It demonstrates the team’s commitment to progressing technology-driven care coordination for CHF patients (Kirakalaprathapan & Oremus, 2022).
A comprehensive risk assessment approach can manage potential challenges and uncertainties for CHF management. This method enables healthcare experts to identify issues before they heighten into significant problems. The risk assessment team initiates this process within the interprofessional care coordination and nurse-led transitional care programs. Team evaluating specific areas such as discharge planning, patient education, and follow-up care of CHF patients (Wu et al., 2024). Challenges such as limited access in underserved areas, inconsistent nurse-led program implementation, and gaps in patient engagement remain persistent. To enhance care coordination and patient outcomes, the team identifies these risks, promotes open communication to address concerns, and prioritizes them for resource allocation. Additionally, external experts consulted as needed to address risks effectively (Wu et al., 2024).
Planned Actions for Effective Resource Use and Safe Care Coordination
Care coordination can be enhanced by prioritizing ongoing CHF patient education on self-management. This approach will ensure that the interprofessional care coordination team is proficient in leveraging nurse-led programs. Additionally, utilizing telehealth solutions and boosting patient-family engagement will advance resource utilization and create a safer environment. Continuous training and education should be tailored to address specific needs and updates related to telehealth (Zhang et al., 2023). Planning for the nurse-led transitional care management program involves evaluating CHF patient needs, developing personalized care plans, and collaborating with the interdisciplinary team.
Key components include patient education, medication management, and symptom monitoring, supported by structured communication protocols. CHF patients are expected to experience reduced 30-day readmission rates, improved medication adherence, and enhanced self-management skills. These outcomes will lead to better health, fewer hospital visits, and more efficient use of healthcare resources. Assumptions include having resources for telehealth education and active engagement from the healthcare team. In a nurse-led program, ongoing evaluation and adaptation are vital for the success of CHF management. This includes training nurses in telehealth, maintaining consistent patient engagement, and adjusting care plans based on feedback (Zhang et al., 2023).
To maintain positive outcomes in managing adult CHF quality improvement, initiatives must be implemented and driven by regular evaluations and feedback. Benchmark activities are employed to compare care coordination outcomes, helping to sustain the achievements made by the interprofessional care team. These strategies strengthen adherence to treatment plans and create a safer, more effective environment for managing CHF patient outcomes (Li et al., 2021).
Conclusion
This assessment discusses how care coordination is enhanced for CHF patients through a nurse-led transitional care management program in ambulatory settings. It highlights the benefits of personalized care plans, patient education, and EHR integration to decrease hospitalization rates and enhance results. The video also emphasizes stakeholder engagement, quality improvement, and leveraging telehealth to address challenges and ensure effective, patient-centered care.
References
Chestnut, V. M., Vadyak, K., McCambridge, M. M., & Weiss, M. J. (2021). The impact of telephonic follow-up within 2 business days postdischarge on 30-day readmissions for patients with heart failure. Journal of Doctoral Nursing Practice, 14(1), 43–49. https://doi.org/10.1891/jdnp-d-19-00079
Khan, S. U., Khan, M. Z., & Alkhouli, M. (2020). Trends of clinical outcomes and health care resource use in heart failure in the United States. Journal of the American Heart Association, 9(14). https://doi.org/10.1161/jaha.120.016782
Kirakalaprathapan, A., & Oremus, M. (2022). Efficacy of telehealth in integrated chronic disease management for older, multimorbid adults with heart failure: A systematic review. International Journal of Medical Informatics, 162, 104756. https://doi.org/10.1016/j.ijmedinf.2022.104756
Ledwin, K. M., & Lorenz, R. (2021). The impact of nurse-led community-based models of care on hospital admission rates in heart failure patients: An integrative review. Heart & Lung, 50(5), 685–692. https://doi.org/10.1016/j.hrtlng.2021.03.079
NURS FPX 6614 Assessment 3 Disseminating the Evidence Scholarly Video Media Submission
Li, M., Li, Y., Meng, Q., Li, Y., Tian, X., Liu, R., & Fang, J. (2021). Effects of nurse-led transitional care interventions for patients with heart failure on healthcare utilization: A meta-analysis of randomized controlled trials. PLOS ONE, 16(12). https://doi.org/10.1371/journal.pone.0261300
Li, Y., Fu, M. R., Fang, J., Zheng, H., & Luo, B. (2021). The effectiveness of transitional care interventions for adult people with heart failure on patient-centered health outcomes: A systematic review and meta-analysis including dose-response relationship. International Journal of Nursing Studies, 117, 103902. https://doi.org/10.1016/j.ijnurstu.2021.103902
Raat, W., Smeets, M., Janssens, S., & Vaes, B. (2021). Impact of primary care involvement and setting on multidisciplinary heart failure management: A systematic review and meta‐analysis. ESC Heart Failure, 8(2). https://doi.org/10.1002/ehf2.13152
Samal, L., Fu, H., Djibril, C., Wang, J., Bierman, A., & Dorr, D. A. (2021). Health information technology to improve care for people with multiple chronic conditions. Health Services Research, 56(1), 1006–1036. https://doi.org/10.1111/1475-6773.13860
Sokan, O., Stryckman, B., Liang, Y., Osotimehin, S., Gingold, D. B., Blakeslee, W. W., Moore, M. J., Banas, C. A., Landi, C. T., & Rodriguez, M. (2022). Impact of a mobile integrated healthcare and community paramedicine program on improving medication adherence in patients with heart failure and chronic obstructive pulmonary disease after hospital discharge: A pilot study. Exploratory Research in Clinical and Social Pharmacy, 8, 100201. https://doi.org/10.1016/j.rcsop.2022.100201
NURS FPX 6614 Assessment 3 Disseminating the Evidence Scholarly Video Media Submission
Wu, X., Li, Z., Tian, Q., Ji, S., & Zhang, C. (2024). Effectiveness of nurse-led heart failure clinic: A systematic review. International Journal of Nursing Sciences. https://doi.org/10.1016/j.ijnss.2024.04.001
Zhang, N., Li, Q., Chen, S., Wu, Y., Xin, B., Wan, Q., Shi, P., He, Y., Yang, S., & Jiang, W. (2023). Effectiveness of nurse-led electronic health interventions on illness management in patients with chronic heart failure: A systematic review and meta-analysis. International Journal of Nursing Studies, 104630. https://doi.org/10.1016/j.ijnurstu.2023.104630
