- NURS FPX 6030 Assessment 6
Abstract
Cardiovascular diseases today are considered to be chronic diseases on a global level, and patients suffering from it are prone to be hospitalized. Focusing on the fact that such readmissions only increase the costs and harm the patients’ health, it is possible to conclude that their management has to be changed (Wideqvist et al. , 2021). This study aims to determine whether nurse case managers’ education and subsequent follow-up interventions can reduce the 30-day readmission rate for heart failure, compared to heart failure patients who receive standard care but no follow-up by a nurse case manager.
The target or study population of interest is the patients with heart failure who were discharged from the hospital (P). Education and follow up plan incorporated in the intervention (I) is a nurse case management-based education and follow-up plan. It refers to educating the patient on drugs, dealing with his or her disease, and organizing the patient’s treatment process. The participants in the control group (C) will receive the standard care from the nurses but they won’t be assisted by the case managers. Main dependent variable (O): If a client is discharged and readmits themselves to the same hospital, this will be mainly be within one month of discharge.
It may be possible for example; Quality of life, adherence to medical regime, cost of health care, and even the state of the patient’s psychological well-being. The study is carried out to a certain time point (T) and all the subjects are followed up for at least 30 days after discharge from the hospital to assess the main outcome. The main objective of the current project, therefore, serves to establish the extent to which the nurse case managers perform this duty by reducing the number of patients who are likely to be readmitted to the hospital within a 30-day interval.
Introduction
For this reason, heart failure has to be addressed in order to make the patient’s result better and reduce the burden on the health care system. According to the new report by the American Heart Association, it is confirmed that heart disease remains the leading killer in the United States (Benjamin et al. , 2019). The patients with heart failure are, for example, frequent revisits to the clinic hence they have low quality of life and bears a lot of pressure on the health facility. It is with this view that this measure should be taken if they are to be helped.
The participants of the study include the heart failure patients who recently got discharged from the hospital and require additional knowledge and further support. Nurse case management is one among the strategies that would be recommended to restore the situation. Heart failure patients are going to receive their control and support after they leave the hospital from actualized nursing professionals (Grant, 2022).
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This comprises of, following the doctor’s instructions on the use of medication, monitoring their own signs and symptoms, altering their diet and coordinating with other professional care givers. The idea is to raise the awareness of a person about his/her sickness and teach him/her ways to cope with he or she illness without having to be readmitted to the hospital.
It has been noted that nurse case management increases patients’ knowledge, adherence to medications and other treatments, and expressions of side effects (Woods et al. , 2019). The rationale for this intervention is the reduction of the 30-day readmission which transforms self-care in an inpatient setting to self-care in a community setting in collaboration with tailored support and quantification. The human resources which will actually implement the intervention would be specialised clinical nurse case managers: Further, clinical nurse case managers will have to be recruited and trained.
Furthermore, there will be a need to develop protocols for counseling and follow up of the patients, and due to the complexity of the conditions, healthcare facilities will require collaborating on how to identify eligible patients during the discharge plan (Kelly et al. , 2019). The patient will be provided with explicit instructions on the time frame for returning crucial disposition of when the patient will have to return for follow up and the tracking and communication protocols that involve the nurse case managers will also be included in the release plan.
To assess the success of the intervention evaluate the 30 day return rates of the heart failure patients who underwent nurse case management against the normal discharge patients who received treatment but no follow-up upon release. Patient satisfaction, self-management, and quality of life will also be evaluated to find out how well the formulated strategy succeeded.
Problem Statement
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Need Statement
According to the findings of the study, the most affected patient population is that of heart failure patients who are highly likely to be readmitted to the hospital within the first month of discharge. Lack of proper information and follow-up care leads to the readmission of patients and this is very expensive with negative impacts on the patient (Samuel et al. , 2022). This study attempts to answer that question by comparing how effectively nurse case managers educate and monitor students after sessions, to usual patient education that does not entail the services of nurse case managers (Mendes et al. , 202^).
The tactics that are related to the implementation of the above-stated strategy are nurse case managers who visit heart failure patients frequently after their discharge or even admission in a healthcare facility, and provide them with sufficient information. Basically, the goal of the project is to identify how patients’ knowledge can be enhanced, how their condition can be made manageable, and how they can adhere to the treatments properly. This is one reason that prevent readmission and enhance heart failure patient’s quality life.
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People and the setting
The target group for this intervention is clients with heart failure who have been recently discharged from the hospital. Such patients may return to an outpatient centre or a home health service where the nurse case managers can teach them. The best approach in this study is therefore to establish if the nurse case management with teaching and follow up reduces the proportion of heart failure patients who would be readmitted within 30 days compared to usual care without such astringent follow up.
They mentioned that the plan could be to select patients randomly and assign them to the nurse case management intervention and or usual care and then compare how often they had to return to the hospital. They might influence development of the remedy and provide a ground for the outcomes.
While making a look at the Intervention, it is worthy to note that nurse case management has been found efficient in keeping heart failure patients away from the hospital for longer periods. Nurse case managers are involved in these programmes and assist the patients to get information on how to communicate, and how they can deal with their care once they are discharged from the hospital (parents, 2019).
NURS FPX 6030 Assessment 6 Final Project Submission
Much of this means getting to patients’ houses for assisting with their medications, assessing complaints and engaging other physicians. Many papers reveal that nurse case management treatments reduce the number of heart failure patients who have to be readmited to the hospital within one month as compared with the usual post-discharge care (McCants et al. , 2019). The aim is to educate people with enough information and assistance or enable them to notice others’ conditions and disease changes on their own at the earliest opportunity. This will better impact on the patients and ease the pressure on the health care systems.
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Interprofessional Teams and Their Use
monitoring and taking care of the patient with the assistance of the Nurses, Doctors and Social workers. According to Baetselier et al. (2021), nurses would educate patients on their situations and how to manage their symptoms; doctors would ensure that patients complied with the intake of their prescription; and social workers would assist people with social requirements such as transport and home attendants. This all-around team based care could help to assume the many facets of the life of the patient with heart disease.
A virtual tracking tool that can be implemented using telehealth and is preferred to be done by a nurse practitioner or a physician assistant (Knight & Prettyman, 2020). From this point, the patients would be equipped with home tracking devices and the online meetings with the clinical team would take place occasionally. This method, utilizing technology, could increase the access to care, increase the rate of early identification, and reduce the necessity of direct consultations; it could also offer comprehensive follow-up care after release. Both depend on the collaboration with individuals from other professions in order to address the particular needs of this type of patients.
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Outcome
Initially, the aim of the capstone project was to reduce the rate of heart failure patients who are readmitted within a 30 day period using an intervention that includes teaching by the researcher and follow-up from the nurse case managers than a usual group of patients that would not receive any follow-up by specialized nurse case managers. The aim of this result is to reduce hospital readmissions, which are unwarranted and prove detrimental to heart failure patients as they are a vulnerable population. This may enhance their health status and reduce expenses of the service they have to pay.
Patients diagnosed with heart failure will be trained and closely monitored from their discharge by nurse case managers (Mizukawa et al. , 2019). The number of days to 30 days will then be used to compare the rates of return of the people that were under the trained nurse case management to those of people that received standard care without any case management.
Previous research has confirmed that skills of a trained nurse case manager in aspects like planning of discharge, education of the patient and coordinative care is effective in reducing hospital readmission rates (Kripalani et al. , 2019). This is particularly the case in patients with chronic illnesses such as heart failure. Assisting people as they are transferred from the hospital to their new home enables them to comprehend their illness, drugs, and measures of self-care. The following SMART conditions are met by this result statement:The following SMART conditions are met by this result statement:
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Specific:
Decrease the readmissions rate within 30 days of the individuals diagnosed with heart failure. It is possible to record the rates of return within 30 days for productivity comparison.
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Possible:
Subsequently, to teach and monitor, nurse case managers can be utilised
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Important:
Because it concerns itself with something notoriatively prevalent in the healthcare sector, workplace readmissions, it is a compelling narrative.
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Time-bound:
More so, focused on the 30-days return rate after discharge was taken.
Thus, it is quite clear that if heart failure patients are educated and followed up by nurse case managers for 30 days, they may not require frequent readmission to the hospital as those, without trained nurse case managers. In the first week, the subjects will be identified as well as the measurements, taken Baseline. Training classes and plans for release would take place in the second and third weeks of the project.
What you would be discussing in week 4 would be; /symptoms, medications and follow up after being discharged. As for Weeks 2-4, the data processing and the first report would also be made. The results obtained and the impact of the strategy on the 30-day return rates would be determined in the analysis of the data gathered in the last two weeks (Schaffer et al. , 2021). The key purpose of this method led by the nurse is controlling the costs of preventable readmissions and enhancing the care of patients.
Literature Review
The pieces this paper discusses explain that nurse-led treatments are crucial regarding enhancing the standard of living of the people with HF by educating them and providing them transitional care. In a similar clinical study with similar findings, Awoke et al.
(2019) also established that the patients and their families benefited from further education by nurses, to enhance their acquisition of knowledge on the necessity of self-care and to possess higher self-care behaviours, though the 30 days readmission rate did not record any variation. Also, Nair et al. (2020) conducted a study to enhance the quality of the followup meetings after the patients were discharged and this decreased the readmission rate of HF patients who were discharged within the 30 day period.
Jaarsma et al. (2020) described self-care as very relevant for people with HF and mentioned that each patient should receive individual support on the matters such as food, exercise, and perception of symptoms. Huynh et al. (2019) applied risk stratification to select potential patients for receiving additional, frequent DM. This made the rates of short-term return or death reduce thus proving that the treatments given were individual.
To prevent patients being readmitted to the hospital, Ryan et al. (2019) stated that they required individual patient centred care plan and then Axelrod and Ryan (2018) noted that patients also required ongoing teaching. They also said that nurses were very instrumental in ensuring that the client realize that it is safe to be transfered from the hospital to their home. Toukhsati et al. (2019) discussed that management of self-care treatments may assist to reduce the readmissions of the people. They also recommended improved reports and to apply behaviour change theories to obtain improved outcome.
Son et al. (2020) also did a meta-synthesis, which explained that follow-up interventions on HF self-care by nurses would reduce on readmission and mortality. The writers did say this however the data in many of these studies was not recorded in the same way the writers also recommended more clinical randomized controlled studies to confirm the efficacy of these results.
According to Takeda et al. (2019), disease management is required to tackle heart failure since it is a common ailment, and many people succumb to it globally. To do this, the writers carry out an analysis of the literature and outline the advantages of their approaches, such as case management, clinic-based models, multidisciplinary care, among others. Despite the fact that they do not have much statistical evidence on the death rates, studies by them hints that all-cause mortality could be decreased especially with case management and different treatments. For instance, case management may assist in decreasing readmission for clients with heart failure reducing the rationale for more active patient management.
When using MI, Vellone et al. (2020) selected self-care in heart failure patients as it aimed to improve the patients’ health-related behaviours. In their randomize control trial, the authors find that MI is effective in increasing the upkeep and management of self-care, with or without unpaid care-givers. Much of the study involved discussion of how patients can be drawn into participation and extricate themselves from ignorance or unhealthy practices for the general health of a community.
Ba et al. (2020) examine the problem of transitional care treatments in patients with the heart failure. Ideally, this would require reducing the frequency at which such patients re-visit hospitals and enhance their total well-being. In what concerns the related information on how to look after the patients who suffer from heart failure, the main issues are highlighted within the frames of the patients’ general check-up without paying enough attention to such conditions and disclosing the ways of management after discharge.
The review did acknowledge the application of transitional care interventions but presented the fact that research exists which does not contain information regarding influence of these interventions on clinical and patient related results. This goes to illustrate just how much more research is called for.
The findings of articles present the significance of interventions delivered by the nurse for the patients with HF, including the teaching, transferring the care from the hospital to home, and particular interventions to reduce the readmission rates and enhanced self-care.
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Existing Health Policies Impacting the Approach
Various healthcare policies and regulations in United States govern the factors that lead to readmissions of patients with heart failure and how the nurse case management can prevent Such occurrences. The ACA also put into place the Hospital Readmissions Reduction Program (HRRP) which penalizes hospitals for being ‘high’ users of the 30-day readmission rate focusing on conditions such as heart failure (Gai & Pachamanova, 2019). This policy is aimed at ensuring that there is quality transfers care in hospitals through implementation of a nurse case management to prevent individuals from re-admission to hospital and likely to be penalized.
Under MACRA’s Quality Payment Program, healthcare workers such as nurse case managers are rewarded for embarking on activities that deliver increased and timely quality care. Ways of value-based care include care planning for patients and patient teaching which are features of nurse case management (Jones et al. , 2019). This strategy is in accordance with the procedures of those models.
The Nurse Reinvestment Act, which is now law was supposed to solve the deficiency of nurses in the United States by providing money for nursing education, employment of nurses and retention of the working nurses. Thus, the policy can support the expansion of nurse case management programmes that require skilled nurses and funding (Gale, n. d. ). Value-Based Purchasing (VBP) programs have been the main encouragement towards making companies within the healthcare sector to enhance their services with lower costs (Lee et al. , 2019).
For example, VBP programs for heart failure can consider return rates, the schedule of drugs, and patients’ satisfaction with their care (Wadhera et al. , 2020). VBP ensures that healthcare centers handle heart failure prevention, patients’ education and care planning in this regard since payment is tied to things like hospital readmission rates and patients’ satisfaction ratings. This in a way enhances the outcome for the patients.
Using these modern health laws and policies, healthcare groups can find out how to utilize the NM and the NCM to assist persons having heart failure. This could involve offering money in exchange for something, emphasizing on the value care it has, concern with the scarcity of nurses, and the policy regulations of the state in question.
Intervention Plan
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Intervention Plan Components
The parts of the action plan were made to be perceived based on the audience and the situation. This plan was designed to reduce the rate at which patients diagnosed of heart failure have to return to the hospital within the first one month of discharge. The parts are educating the patient and then involving the nurse case manager, and the comparator was normal care without the presence of trained nurse case management.
According to Parnell et al . (2019) health literacy enables people to understand their condition, possible symptoms, they may be prone to and explanations of why it is crucial for patients to follow their treatment regimens. Thus, from the perspective of follow-up in nurse case management, the patient is provided with direct care, assessment is made, and the care of the patient is managed. This part compares the solution being tested to what is essentially the standard or normal care, which does not even incorporate follow-up care by a trained nurse case manager.
Talking about the action plan and all senior stages, the characteristics of the target group’s culture and needs, as well as the setting, impacting various segments of the action plan are considered. Culture influences a patient’s beliefs, concerns, perception towards health, illness, and therapy more especially the traditional African culture (Shahin et al. , 2019).
Thus, the self-care plans and training tools to be used by the people must be commensurate to the region. The plan also includes factors such as language, reading ability, and how easily one can access medical services in the selected neighborhood (Ilardo & Speciale, 2020). From focusing on a target group, it may be easier to converse with the CHWs, other people in that group or all the participants and get them to accept the solution more resulting to good results.
Explaining how specific treatments of long- term illness such as the Chronic Care Model can be useful for illustrating the evolution of care for patients with heart failure. This model presents readiness and aggression on the side of the professional practice teams and involvement and knowledge on the side of the patients (Martínez et al. , 2021).
Some of these are: To care for the patient, which has its focus on the patient, practice services, support with self-care, assistance with lifestyle management, delivery models, decision making, and the use of clinical IT solutions. In this model, nurse case managers can explain the necessary home care and treatment regimen, monitor the patient’s progress, guarantee the patient follow the treatment plan, watch for signs and symptoms, and ensure that the patient receives all the needed care (Joo & Liu, 2020). Cross-sectional studies have demonstrated that the Chronic Care Model interventions reduces the proportion of the people who require to be admitted to the hospital and die of heart failure.
The remaining theory is Orem’s Self-Care Deficit Nursing Theory, which can also be applied in this work. It points that nurses can assist people understand how to take care of themselves in case the status of their health is altered (Gligor & Domnariu, 2020). This theory can be used by the nurse case managers to assess the patient’s self-care behaviors in relation to foods, exercise regimen, medication adherence, and symptoms (Griffin et al. , 2019). This contributes to the formulation of individual lessons by teachers which will enable each learner to enhance on their cleaning habits as well as their self esteem. In the light of this particular conception, self-care programs that were employed were associated with a reduced heart failure population that were readmitted to hospital.
Motivational questioning is an essential technique applied when treating drugs, which also can be useful in other areas of work, including those of nurse case managers. Assertiveness training method of client-centered therapy enables the patients to grasp and cope with anxiety related to behavioral change (Burke et al. , 2021). Motivational interviewing is the strategy that the nurse case managers may apply in order to elicit the appreciation of the beneficial (+) aspects and identification of the undesirable (-) aspects of patients’ adherence to the recommended medication intake, as well as increase patients’ self-confidence regarding the identification of potential obstacles to the proper implementation of the action plan, which should be pursued to reduce the likelihood of readmission (Khadoura et al. , 202
Thus, the business area of customer relationship management (CRM) has another useful method that can be used here. Likewise, as businesses follow up with their customers constructing trust, more personalized timely and tender follow up could promote the nurses and the patient’s relationship so that goals of the care plans could be achieved (Magatef et al. , 202·). CRM stands for communication and relational management that means that calling or texting patients or making a home visit and giving them related information according to their preferences. Studies reveal that understanding and education about the patient decreases the likelihood of revisiting the hospital for heart failure in line with communication and teaching.
Healthcare tools may also be applied to expand existing detailed procedures to the plan of action. It is worth noting that nurse case managers can monitor patients’ state, assess their conditions and assist them without visiting their homes (Abraham et al. , 2023) due to web-based telehealth and monitoring. Using EHR and CDS, the focus on the patient data, alerting to risks, and idea generation relies on facts, and this is beneficial for nurses (Sutton et al. , 2020). Some knowledge published in the last few years via systematic reviews and meta-analysis has revealed that nurse case management has led to an increase in the period of time that heart failure patients stayed out of hospitals, especially where nurse teaching features; follow up and care planning are inculcated in the program.
Nurse case management for heart failure patients and its efficiency is influenced by policies, rules, governing bodies that regulate the work of health care providing centers, organizations, companies, and the people who are interested in the issue. Patient, health care employees, insurance and policies are the main participants that are affected by the issue. All these groups have different requirements that have to be fulfilled.
The people need accessible and affordable care. Clinicians have to apply evidence-based approaches and get the wages noted below norms (Bernstein & Wang, 2021). Insurers seek to incur low expenses, which ERA 2 entailing the provision of health care to the entire population in the most efficient manner, is contrary to the goals of policymakers.
The healthcare policies like the ACA and the MACRA in the US have impacted models of care like nurse case management (Borders et al. , 2023). Some rules drawn by such organization’s as the Joint Commission on Accreditation of Healthcare Organizations and the Centers for Medicare and Medicaid Services are used for patient care, health, and safety (Willis, 2021).
These rules and policies can assist or damage nurse case management programs possibly influencing the extent of their efficiency in preventing heart failure patients from being readmitted to the hospital. Policies in LXXXX, rules regulating workplaces, and practices of each country’s healthcare system could influence the applicability of the nurse case management methods. Awareness of these things is key for a good outcome, and to attain the improvements that were expected: for instance, that less heart failure patients will have to re-admit to the hospital.
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Legal and moral problems
That is why respecting a patient’s right to make decision for himself and give an informed consent is very crucial. Any participant enrolled in the nurse case management program should be informed of the program’s advantages and their right not to participate (Jackson et al. , 2019). Both HIPAA rules and safety of the patient’s information are some of the responsible things that should be followed to uphold their right to privacy and security (Issa et al. , 2020).
Also, the action should be based on the concept of beneficence where we mean doing good. The focus should be on the result of patients’ treatment and their quality of life (Varkey, 2021). However, there is a possibility of experiencing ethics problems whenever there is conflict between the patient’s desire and the doctors advice.
Other laws/rules relating to the health care organizations include patient rights, data safety and the nurse area of practice. Thus, there must be some standards and procedures concerning the works of the nurse case managers and paperwork that are to be adhered to by everybody to avoid getting in trouble with the law (Tajabadi et al. , 2019). If something goes wrong much due to negligence or poor management of care, then there could be legal issues. To reduce the legal risks for the action, the appropriate risk management tools have to be utilized which includes training, supervision and libel insurance.
Going by the hints from the research, the nurse case management program tends to operate within the rules of law and ethics. The concept of it is that people themselves are able to make a decision and that other health care providers will respect that decision. Moreover, it is also assumed that staffing and data security risks have sufficient resources to continue their operations as well as maintain and introduce laws standards.
Implementation Plan
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Management and Leadership
The following processes should be followed in order to successfully lead as well as manage the execution of an intervention plan for nurse case management with a view of decreasing the number of readmissions of patients diagnosed with heart failure. A perfect example of a model of change is Kotter’s 8 step change management model. This entails identifying for what reason change is required, assembling the correct people, developing the vision, communicating the vision, providing tools to others to enable them address change, managing the change as a process and reinvesting in change, as well as embedding and sustaining the change, Mayo, 2021.
This strategy requires different people to work together and such people can be professionals from various fields. Factor such as communication, outsourcing and ensemble participation of all the workers in the healthcare facilities who attend to heart failure patients ease working relations (Hsieh et al. , 2020).
Out of the four core components of Leaders, Co ordinators, Volunteers , and Recipients reviewed above, Leadership is a key factor for engaging people, countering resistance, and organizational coordination of care delivery contexts (Elliott et al . , 2020). Thus, making patients less likely to be readmitted and keeping them healthier, the quality of care can be raised while the expenses are still kept down.
However, even if the suggested solution is implemented then it might experience some difficulties like the aspect of the quantity of resources that would be available, the mood of the staff, and the aspect of caring that is given in different places. Such effects should be considered by methods of change management and responded to accordingly. Thus, it will be crucial to continue scrutinizing the process and tweaking it in order to permanently prevent these issues from occurring and sustain the favorable impact of the process change on patient outcomes and costs.
Precisely, face-to-face and online approaches can both be useful for a fix where it stopped heart failure patients from returning to the hospital. It indicates that, face-to-face communication like home visits or clinic appointments would enable the Nurse case managers educate, examine and assist the patients much better (Cohen et al. , 2020).
It also stressed the importance of routine visits, symptom follow-up, and the initiation of initial therapies mentioned that teleconsultation or telemonitoring could also be utilized to assist with ongoing government examinations (Cheng et al. , 2022). Even though these ways of giving care contribute to client-centredness, they would assist the nurse case managers to have an understanding about the patients, the compliance of the patients to their regimes and any presents or complications requiring attention to address.
Today, quite a few healthcare groups apply EHR and telemedicine. However, based on new interventions such as artificial intelligence and virtual reality the implementation of interventions may be a bit more straightforward (Antel et al. , 2022). Decision support tools can assist nurse case managers on how they can view information to do with patients and come up with certain plans in a particular aspect.
Augmenting applications can be employed in the training of patients since they can be placed into life like situations to learn on how to manage themselves (Koulas et al. , 2021). Probably, when such tools are integrated with conventional approaches, they can increase the efficiency of nursing interventions for heart failure patients and minimize their readmissions.
It goes without saying that organizing an intervention plan for the heart failure patients with the use of the nurse case managers turned into a multiple personnel and legal issues scenario. People suffering from the disease, healthcare providers – nurses, and physicians – hospitals, and insurance companies would be the major stakeholders to be prominently focused.
Patients in terms of general health would have improved results, and in some cases, the cost of readmissions of Healthcare workers and hospitals (Breckenridge et al. , 2019). The beneficiaries would include the patients in the aspects of care management and reduced readmission. And, the insurance firm costs would also reduce due to low readmission rates.
Regarding the policies the Centers for Medicare and Medicaid Services begin some numbers of programs that reduce the readmissions of hospitals. For instance, the Hospital Readmissions Reduction Program (HRRP) penalises hospitals with higher than benchmark rates of readmissions among patients with heart failure, and other ailments (Gai & Pachamanova, 2019).
Also, the ACA grants programs for transitional care management as well as the chronic care management that could potentially accommodate nurse case management (Joo & Liu, 2021). There are also some specific states that have also introduced their own policies and regulations forbidding individuals to be readmitted.
People with heart failure will get the management plan that will be in place, and the process followed strictly for 4 weeks with specific focus on adhering to the laid down routine. During the first week, people will be recruited into the study and preliminary data collect will be conducted to lay the foundation for the subsequent measures.
Subsequently, in the next two and three weeks, detailed activities and training schedules will be conducted for the patient as well as plans for their discharge to ensure that the patient learnt enough and is capable for the outside world. Thus, the fourth week if the worst scenario of recontamination and relapse with monitoring of symptoms after release, management of medications, and follow-up care will come. Interim reports checking as well as data analysis will also be conducted in order to ascertain the results (Denis et al. , 2019).
The second and third weeks of the plan will be spent primarily on assessing data and searching for effecting results, as well defining the degree of success in terms of decreasing the 30-day return rates. According to Asgube (2023), this systematic process is chaired by a nurse case manager and is used to enhance the quality of the treatment offered to the patients and to reduce the instances of non-compulsory readmissions by lowering costs for the health care services and elevating the level of health care. This schedule assures that the action will be well-timed and meet the requirements of the targets, namely, the heart failure patients, by allotting varied time to each stage.
The implementation of the plan for people who have heart failure involves the nurse case managers who conduct a four week program aimed at reducing the readmission of individuals to the hospital. The elements are capturing data at the epoch of the primary attendance, educating the patient, outlining the discharge, and post-discharge care, prescribing medicines, and assessing concerning signs.
Patients, healthcare personnel, the hospital, and insurance providers are all involved as components of the plan for it to take effect. Perhaps, such tools as EHRs, telehealth, AI, and VR can help to implement the solution. Measures of prevention of readmissions are contained in the HRRP and some sections of the ACA. In answering the question the action is going to be evaluated solely, with regards to its outcomes, and these will be presented in form of data.
Evaluation of the Plan
Determination of outcome expectations that the intervention plan can provide is an important part in determination of the effectiveness of the nurse case management in ensuring that heart failure patients do not get admitted within one month of discharge. The objective of the study is to determine if the patients with heart failure who are receiving information and follow-up care from the nurse case managers will have a lesser probability of having to be readmitted to the hospital within 30 days compared to the patients receiving regular care without the support of the nurse case managers.
Other potential benefits include improved satisfaction with the condition by the patients, other self care related positive behavioural changes such as medication compliance, improved general health status, and reduced health care costs, largely due to reduced rates of readmissions (Kvarnström et al. , 2021).
Quasi-experimental approach will be used in the making of the evaluation plan. Heart failure patients are split into two groups: while the intervention group receives nurse case management, the control group receives standard care. Patients being the focus of the study are those adults with heart failure that have been discharged from the hospital. Concerning the participants selection, the power analysis guided the determination of the group size.
It is collected by observing computer patient charts to realize which patients have to be readmitted, by polls to understand patients’ perceptions of their conditions and the extent of their ability to cope with those conditions, and by engaging with patients to know about their level of happiness and health (Mahmoudi et al. , 2020). The work of evaluating the level of economical efficiency of the action is also includes a cost-benefit study as part of the review plan.
The evaluation method that has been proposed consists of several stages. Initially, concerning return rates, patients’ awareness, and self- management abilities is gathered prior to the action (Cone, 2022). There is the intervention in the middle, and then there’s the readiness to follow through and make changes. The intervention group is taught by nurse case managers and after the intervention, the case managers offer care for some time, for instance, thirty days after release.
Samples are collected at certain points in time during the time of the intervention and at the end of the 30-day post discharge period. The gathered information is then analyzed in order to determine if there is a statistically significant difference between the groups with the intervention and the control groups in relation to the return rates and other variables (Becker et al. , 2021). Last, the outcomes are discussed, and suggestions on how the intervention may be deployed in the future along with ways on how the study could be developed if it proves successful in decreasing the readmissions rates and enhancing the patients’ quality of life, are presented.
It is believed that, thanks to the quasi-experimental design, the sources of confusion have been minimized and there are enough participants in the study so that differences between the control group and the intervention group can be observed.
It also assumes the samples selected for the choice of result measures are valid and appropriate for determining how the intervention functioned; as well as for the assumption that the chosen data collection techniques are good and utilized normally. The study also wants to presume that the intervention is implemented and delivered to a ‘T’ and that the participants adhere to the suggested care plan.
Discussion
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Advocacy
Nurse leaders can play a vital role in change and increasing the quality of care and patients’ experience of IHD individuals. Since they are the front liners in skin care, nurses are in a peculiar position to note gaps that exist and fill them with evidenced practice (Rosa et al. , 2021).
The following are some of how nurse case managers can help reduce the instances and rate of early readmissions within the 30 days of release Their successful education and supervision programs. By communicating with the patients, patients’ families, and the other members of the healthcare team, nurse case managers can ensure that their patients are prepared to manage their conditions at home (Luther et al. , 2019).
Another area in nursing and collaborative practice has been touched by the intervention plan: teaching, as well as follow-up by means of nurse case managers. A nurse case manager plans a patient’s care and collaborates with doctors, pharmacists, social workers, and more to ensure that a patient receives the best care possible.
This complete model fosters incorporating the patient in the activities and decision-making process, sharing information and collaborative approach. Employing the information of people from different fields, nurse case managers are able to develop sound care plans for the people having heart failure when they collaborate with other professionals (Clarke, 2020).
Thus, the planned plan for involvement will be positive for the whole sphere of healthcare. The plan aids in enhancing the patients’ health, and their overall quality of life as well as reducing the expenses to accomplish health care needs by minimizing readmissions to the hospital (Warchol et al. , 2019).
The unfortunate thing is, heart failure patients want to live longer and have a better quality of life if only they get the right information feeding and follow up care showing that if such a patient has heart failure, they are likely to take care, adhere to the management regime and recognize when they are deteriorating. It is steps like these that may help avoid people needing to go to the hospital or having things that are not good happen, which is really using the healthcare system to its potential.
Hence, the present project focuses on the readmissions of heart failure patients within a limited period of thirty days of discharge. However, following changes can be made to make it more useful. The nurse case managers could first provide more and more individualized information to every single customer they deal with. One of them is the increase in the extent to which the knowledge that is passed on to each patient could be made to correspond to the patient’s need, thinking, and cultural barriers (Kaihlanen et al. , 2020).
As well, the follow-up procedures should be enhanced through frequent check-ups on people and monitoring of health. Thus, the nurse case managers could monitor the patients’ condition, including the changes in the vital signs, the emergence of specific symptoms, and the patients’ compliance with the treatment plan using video. If it was necessary they could start intervening early.
On a similar note, it may also be argued that such a project may require utilizing new tools and methods of offering care that would enhance the patient’s recovery and safety. Introducing the smart phone and other forms of personal sensors that can enable patient tracking increases the capability of providing real-time information of a patient’s status to alter the current treatment plan to avoid the occurrence of negative incidences (Andrews et al. , 2019).
Furthermore, the patients would be better off seeing the enhanced involvement of nurse case managers, the primary care physicians, cardiologists, and other health care personnel on a shared care plan (Raat et al. , 2021). The following plans can also be used with patient-centered care which focuses on engaging the patient in his/her care and treatment to enhance the quality of the outcome and reduced rate of hospital readmission:
Imagining on how change can be managed and how things can be improved.
The project has helped individuals do such a better job on change management in own area of work and in other leading positions. Through the provision and analysis of the intervention, transformational, collaborative and situational leadership has been learned in a big way. Transformational leadership mobilised the aspirations of the group and focused on getting the participation of the group while democratic leadership facilitated the working and decision making of the group (Klaic et al. , 2020).
Situational leadership provided a much needed flexibility in terms of the approach that the leaders used for adapting to the needs of the teams and the overall phase of the project (Walls, 2019). Such types of leadership have been very useful in dealing with change and enhancing the patient’s experiences of Heart failure.
The ideas that are elaborated in the project regarding action, implementation as well as review can be applied immediately in practice in order to enhance quality in other centres. The primary elements that people in various healthcare environments and those with various patient populations often utilize are the main steps of defining the problem, finding a solution, implementing the idea, and assessing the degree of success. Thus, the teaching and follow up strategies employed by the nurse case managers can also be employed in other chronic disease management programs in order to enhance patient outcomes with reduced admissions (Briz et al. , 2020). This is an area that you will need in the future to enhance the quality of personal and working life and hence you can use the skills and experiences you got from this project.
Conclusion
The aim of this project was to determine the variety of 30, days return rates regarding to teachings and follow-up activities of a nurse case manager in heart failure patients. Therefore, with the help of the ideas and methods, reading in different fields, it was possible to make a thorough action plan. The assessment plan proposed the use of quasi-experimental design to determine the frequency with which individuals in the intervention and control arms had to return to the hospital. The project also concentrated a lot of effort on the advancement of nurse leaders to champion change and also enhance the relations between the professionals. The strategy could be more effective in the case of patients and might be cheaper in the future with the use of technologies, mutual care plans, and patients’ involvement.
NURS FPX 6030 Assessment 5 Evaluation Plan Design
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