NURS FPX 6030 Assessment 5 Evaluation Plan Design

Name

Capella university

NURS-FPX 6030 MSN Practicum and Capstone

Prof. Name

Date

Evaluation Plan Design

Chronic Heart Failure (CHF) is an incurable disease that harms the patient’s standard of life. Although CHF impacts a broader population, it is vital to investigate therapy techniques for retaining or improving CHF patients’ quality of life (Freedland et al., 2021). The assessment focuses on evaluating individualized self-management education, coordinated care, and medication management interventions for the health promotion of CHF patients. The study evaluates nursing’s role in promoting change, its implications for inter-professional collaboration, and integrating innovative technologies and healthcare models.

Evaluation of Plan

Defining Outcomes

The intervention plan’s primary goal is to enhance health promotion and the standard of life for people with CHF. Implementing evidence-based approaches to intervention, including individualized self-management education, care coordination, and medication management, improves health outcomes (Baeez & Younis, 2019). The therapies primarily address a critical requirement for CHF patients’ wellness. Self-management education programs aim to reduce hospitalization rates in CHF patients. It enhances their self-management skills and living standards (Baeez & Younis, 2019).

Coordinated care techniques, like periodic check-ups and patient education, aim to lower comorbidities and improve the well-being of CHF patients (Charais et al., 2020). CHF is associated with complications, and CHF patients experience difficulties managing complicated treatment regimens. Improved drug management aims to improve CHF patient outcomes. The intervention plan’s primary goal is to improve health conditions (Kosiborod et al., 2023).

Pros and Cons

The intervention plan aims to enhance adult CHF patients’ quality of life and health promotion through evidence-based interventions, including individualized education on self-management, coordinated care, and medication management strategies. The plan can boost CHF health outcomes by minimizing the difficulties (Charais et al., 2020). Moreover, alternative consequences should be considered. Some CHF patients experience minimal improvement in quality of life, struggle with disease management, and exhibit complex symptoms due to medical history and emotional issues (Nordfonn et al., 2019).

An Evaluation Plan

The plan aims to assess the intervention’s impact on adult CHF patients’ health, tracking health measures like blood pressure changes and evaluating readmission and hospitalization rates (Dessie et al., 2021). The intervention’s effectiveness in improving health outcomes for CHF patients will be evaluated through a survey approach, incorporating feedback and questionnaire responses (Ijaz et al., 2022). The self-management education assessment plan will examine changes in CHF patients’ knowledge, abilities, and comprehension of self-care during the intervention. Indicators include the frequency of involvement in health-related events such as workshops, health literacy seminars, and nutritious lifestyle sessions (Warner et al., 2019).

Surveys of CHF patients and medical professionals can be utilized to collect feedback on the educational program’s success in the intervention (Jiang et al., 2020). Pre- and post-tests can be used to compare improvements in CHF patients’ knowledge, understanding, and attitudes toward medication management and self-care before and after the intervention. The pre-test approach can be used to determine benchmark knowledge and highlight areas requiring further awareness (Jiang et al., 2020). The intervention’s post-test will evaluate self-care and medication adherence changes to establish specific learning and management objectives aligned with the intervention’s objectives (Luštrek et al., 2021). 

Assumptions 

It is assumed that evaluating indicators and feedback will provide valuable insights into the intervention’s success and identify areas for improvement (Ijaz et al., 2022). Similarly, medical professionals can evaluate the effectiveness of educational self-management interventions by monitoring CHF patients’ knowledge, understanding, and perspectives on self-care and medication management through involvement levels and pre and post-tests (Warner et al., 2019).

Discussion

Advocacy

Analysis of the Role of Nurses

Nurses’ efforts are critical in influencing change and improving the quality, health promotion, and CHF patient intervention experience. Nurses can effectively implement self-management interventions for CHF patients by collaborating with multidisciplinary groups to create tailored, coordinated care plans (Son et al., 2020). Nurses should collaborate on cultural competency education, self-care, and medication management interventions, considering the perspectives of CHF patients (Velarde et al., 2023). Moreover, nurses can coordinate with patients and nutritionists to develop healthy lifestyle practices essential for disease self-management (Son et al., 2020).

Additionally, nurses play a crucial role in promoting patient safety and health outcomes. They educate patients on self-management, collaborating with medical specialists, and implementing evidence-based medication adherence strategies (Sieben et al., 2019). Nurses can collaborate with hospital executives and lawmakers to create procedures and policies that facilitate the implementation of quality improvement initiatives for adult CHF patients (Marani et al., 2020).

Assumptions

The assumption is that multidisciplinary teamwork is required to execute interventions such as coordinated care, self-care, and medication management. Nurses can enhance patient understanding and awareness of medication adherence and self-care, leading to improved health outcomes through collaborative efforts. Nurses can educate and help patients develop self-management strategies (Son et al., 2020).

Effects of the Plan on Nursing and Inter-professional Collaboration

Interventions such as coordinated care, self-management education, and medication management can significantly influence nurses and multidisciplinary collaboration (Grover et al., 2022). Nurses must collaborate with medical experts like nutritionists and health educators to ensure effective patient treatment plans, fostering inter-professional collaboration and teamwork (Sieben et al., 2019). The intervention plans can assist medical professionals in communicating and collaborating more effectively. Interdisciplinary teams enhance communication and collaboration among medical providers, while a patient-centered approach motivates them to interact and coordinate more effectively (Grover et al., 2022). Medical professionals work together to provide comprehensive treatment and exchange knowledge on drug management, adverse events, and self-care, fostering enhanced communication and collaboration among team members (Lancey & Slater, 2023). Collaborative care enhances CHF patients’ quality of life (Cui et al., 2019).

Implementing intervention can enhance organizations’ and medical professionals’ reputations and patients’ confidence in evidence-based care, demonstrating a commitment to quality healthcare. The use of these therapies lowers the rate of CHF patient readmission. It helps the organization reserve financial resources that can be employed for other developmental processes (Yu et al., 2022).

Knowledge Gaps

There is a need to explore the involvement of patients and their families in the development and execution of intervention programs for the health promotion and quality improvement of CHF patients. How do medical professionals actively engage patients in their treatment by addressing their issues and desires while providing customized care? Addressing ambiguity and knowledge gaps helps nurses comprehend the advantages and challenges of implementing intervention strategies (Grover et al., 2022).

Future Steps

Improvement in the Current Project

The intervention strategy can improve the standard of life for adult CHF patients by expanding treatment options’ accessibility to a broader range of individuals. Healthcare providers can increase the accessibility and availability of interventions by using telehealth tools and care models, improving productivity and safety (Williams et al., 2020). Telemedicine and health monitoring applications can enhance CHF patients’ health outcomes. Intervention effectiveness can be enhanced by incorporating self-management education (Cardoso et al., 2021).

Health monitoring apps can track adult patients’ health status and outcomes, enabling medical professionals to personalize treatment programs for each patient’s needs (Giordan et al., 2022). Moreover, employing an integrated care paradigm can enhance outcomes and patient safety. The collaborative care model incorporates medical services and self-care into primary care settings, enabling patients to get more integrated and holistic care. Nurses can lower the possibility of adverse events by collaborating closely with medical professionals (Cui et al., 2019).

It is also assumed that patients with CHF will agree and be capable of using telehealth facilities. Medical professionals have the appropriate education and tools to deploy telehealth technology effectively (Williams et al., 2020). Implementing integrated and collaborative care models and self-management is expected to avoid challenges for adult CHF patients and ensure the standard of treatment remains unchanged in healthcare settings (Cui et al., 2019).

Transferring Quality Improvement Plans into Personal Practice

The project emphasizes the significance of evidence-based interventions, multidisciplinary teamwork, and personalized care in enhancing quality in medical facilities through effective intervention strategies (Son et al., 2020). Throughout the capstone project, I have undergone incredible professional and personal transformation. The comprehensive investigation of CHF patient care has enhanced my transformation leadership skills and underscored the importance of collaboration among medical disciplines. My leadership abilities have been tested and refined, establishing a more profound sense of responsibility and dedication to quality care. In the future, I intend to include more evidence-based techniques in CHF care, ensuring that every intervention I conduct is founded on evidence. To deliver holistic and coordinated care to patients, I aim to apply multidisciplinary approaches in my practice with professionals from different sectors in the organization, achieving optimal patient outcomes.

Integration of Intervention Insights into Broader Practice

The insight of an intervention plan has significant effectiveness in healthcare settings. The plan’s combined emphasis on self-management and technology, including telehealth services, assures its adaptability across numerous healthcare conditions. This adaptable strategy includes individualized self-care management, medication adherence, coordinated care supported by evidence-based procedures, and solid multidisciplinary collaboration promoting safety and healthcare (Son et al., 2020). This comprehensive approach supports my practice to provide evidence-based and quality care to patients by developing multidisciplinary collaboration with another health professional. It can serve as a model for quality improvement interventions in various healthcare settings.

Conflicting Data

It is critical to address conflicting evidence in establishing and evaluating an intervention plan of self-care, medication management, and coordinated care to enhance the well-being of CHF patients. For instance, few studies have claimed that self-management has no significant impact on improving quality of life (Noonan et al., 2019). Other physical difficulties and emotional issues impede the success of the intervention. Furthermore, data suggests that exercise-based cardiac rehabilitation benefits CHF patients (Zhao et al., 2021). Additionally, it is critical to understand the perspectives of CHF patients and their families, which can vary from those of medical professionals (Velarde et al., 2023) 

Conclusion 

Evaluating the effectiveness of self-management education, coordinated care, and medication management intervention plans for CHF patients, improving quality and productivity. It is a viable strategy for dealing with health issues. Evaluating the intervention plan enables data collection to aid in identifying the most effective interventions for CHF patients’ management.  The plan can also guide legislators in designing efficient policies and programs to tackle CHF patients’ health challenges.

References

Baeez, Y. K., & Younis, Y. M. (2019). Effect of a health educational program on patients knowledge regarding heart failure: A quasi-experimental study. Erbil Journal of Nursing and Midwifery, 2(2), 125-131. http://dx.doi.org/10.15218/ejnm.2019.16

Cardoso, S. J., Juanatey, J. R. G., Comin-Colet, J., Sousa, J. M., Cavalheiro, A., & Moreira, E. (2021). The future of telemedicine in the management of heart failure patients. Cardiac Failure Review, 7. https://doi.org/10.15420%2Fcfr.2020.32

Charais, C., Bowers, M., Do, O. O., & Smallheer, B. (2020). Implementation of a disease management program in adult patients with heart failure. Professional Case Management, 25(6), 312-323. https://doi.org/10.1097/NCM.0000000000000413

Cui, X., Dong, W., Zheng, H., & Li, H. (2019). Collaborative care intervention for patients with chronic heart failure: A systematic review and meta-analysis. Medicine, 98(13). https://doi.org/10.1097%2FMD.0000000000014867

Dessie, G., Burrowes, S., Mulugeta, H., Haile, D., Negess, A., Jara, D., & Khanam, R. (2021). Effect of a self-care educational intervention to improve self-care adherence among patients with chronic heart failure: A clustered randomized controlled trial in Northwest Ethiopia. BioMed Central Cardiovascular Disorders, 21(1), 1-11. https://doi.org/10.1186/s12872-021-02170-8

NURS FPX 6030 Assessment 5 Evaluation Plan Design

Freedland, K. E., Rich, M. W., & Carney, R. M. (2021). Improving quality of life in heart failure. Current Cardiology Reports, 23(11). https://doi.org/10.1007/s11886-021-01588-y

Giordan, L. B., Ronto, R., Chau, J., Chow, C., & Laranjo, L. (2022). Use of mobile apps in heart failure self-management: Qualitative study exploring the patient and primary care clinician perspective. Journal of Medical Internet Research Cardio, 6(1), e33992. https://doi.org/10.2196%2F33992

Grover, S., Fitzpatrick, A., Azim, F. T., Ariza-Vega, P., Bellwood, P., Burns, J., & Ashe, M. C. (2022). Defining and implementing patient-centered care: An umbrella review. Patient Education and Counseling, 105(7), 1679-1688. https://doi.org/10.1016/j.pec.2021.11.004

Jiang, W., Zhang, Y., Yan, F., Liu, H., & Gao, R. (2020). Effectiveness of a nurse-led multidisciplinary self-management program for patients with coronary heart disease in communities: A randomized controlled trial. Patient Education and Counseling, 103(4), 854-863. https://doi.org/10.1016/j.pec.2019.11.001

NURS FPX 6030 Assessment 5 Evaluation Plan Design

Kosiborod, M. N., Abildstrøm, S. Z., Borlaug, B. A., Butler, J., Rasmussen, S., Davies, M., & Petrie, M. C. (2023). Semaglutide in patients with heart failure with preserved ejection fraction and obesity. New England Journal of Medicine, 389(12), 1069-1084. https://doi.org/10.1056/nejmoa2306963

Lancey, A., & Slater, C. E. (2023). Heart failure self-management: A scoping review of interventions implemented by allied health professionals. Disability and Rehabilitation, 1-12. https://doi.org/10.1080/09638288.2023.2283105

Luštrek, M., Bohanec, M., Barca, C. C., Ciancarelli, M. C., Clays, E., Dawodu, A. A., & Vodopija, A. (2021). A personal health system for self-management of congestive heart failure (HeartMan): Development, technical evaluation, and proof-of-concept randomized controlled trial. JMIR Medical Informatics, 9(3), e24501. https://doi.org/10.2196%2F24501

Marani, H., Baranek, H., Abrams, H., McDonald, M., Nguyen, M., Posada, J. D., & Bhatia, R. S. (2020). Improving the design of heart failure care from the perspective of frontline providers and administrators: A qualitative case study of a large, urban health system. Journal of Comorbidity, 10, 2235042X20924172. https://doi.org/10.1177/2235042X20924172

NURS FPX 6030 Assessment 5 Evaluation Plan Design

Noonan, M. C., Wingham, J., Dalal, H. M., & Taylor, R. S. (2019). Involving caregivers in self‐management interventions for patients with heart failure and chronic obstructive pulmonary disease. A systematic review and meta‐analysis. Journal of Advanced Nursing, 75(12), 3331-3345. https://doi.org/10.1111/jan.14172

Nordfonn, O. K., Morken, I. M., Bru, L. E., & Husebø, A. M. L. (2019). Patients’ experience with heart failure treatment and self‐care—a qualitative study exploring the burden of treatment. Journal of Clinical Nursing, 28(9-10), 1782-1793. https://doi.org/10.1111/jocn.14799

Sieben, A., van Onzenoort, H. A., van Dulmen, S., van Laarhoven, C. J., & Bredie, S. J. (2019). A nurse-based intervention for improving medication adherence in cardiovascular patients: An evaluation of a randomized controlled trial. Patient Preference and Adherence, 837-852. https://doi.org/10.2147/PPA.S197481

Son, Y. J., Choi, J., & Lee, H. J. (2020). Effectiveness of nurse-led heart failure self-care education on health outcomes of heart failure patients: A systematic review and meta-analysis. International Journal of Environmental Research and Public Health, 17(18), 6559. https://doi.org/10.3390/ijerph17186559

Velarde, G., Bravo‐Jaimes, K., Brandt, E. J., Wang, D., Douglass, P., Castellanos, L. R., & Watson, K. (2023). Locking the revolving door: Racial disparities in cardiovascular disease. Journal of the American Heart Association, 12(8), e025271. https://doi.org/10.1161/JAHA.122.025271

NURS FPX 6030 Assessment 5 Evaluation Plan Design

Warner, G., Packer, T. L., Kervin, E., Sibbald, K., & Audulv, Å. (2019). A systematic review examining whether community-based self-management programs for older adults with chronic conditions actively engage participants and teach them patient-oriented self-management strategies. Patient Education and Counseling, 102(12), 2162-2182. https://doi.org/10.1016/j.pec.2019.07.002

Williams, W. C., Rossi, L. P., Bittner, V. A., Driscoll, A., Durant, R. W., Granger, B. B., Graven, L. J., Kitko, L., Newlin, K., & Shirey, M. (2020). Addressing social determinants of health in the care of patients with heart failure: A scientific statement from the American Heart Association. Circulation, 141(22). https://doi.org/10.1161/cir.0000000000000767 

Yu, D., Polly Wai-Chi Li, Shirley Xue Li, Smith, R., Sunny Chiu-Sun Yue, & Bryan P.Y. Yan. (2022). Effectiveness and cost-effectiveness of an empowerment-based self-care education program on health outcomes among patients with heart failure. Journal of the American Medical Association Network Open, 5(4), e225982–e225982. https://doi.org/10.1001/jamanetworkopen.2022.5982

Zhao, Q., Chen, C., Zhang, J., Ye, Y., & Fan, X. (2021). Effects of self-management interventions on heart failure: Systematic review and meta-analysis of randomized controlled trials – Reprint. International Journal of Nursing Studies, 103909. https://doi.org/10.1016/j.ijnurstu.2021.103909 

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