NURS FPX 4030 Assessment 4 Remote Collaboration and Evidence Based Care

Name

Capella university

NURS-FPX 4030 Making Evidence-Based Decisions

Prof. Name

Date

Remote Collaboration and Evidence-Based Care

Good Afternoon audience. Today’s presentation discusses an evidence-based care plan designed for a 65-year-old male patient diagnosed with Congestive Heart Failure (CHF) to carry forward his remote care through interdisciplinary collaboration. Let us begin our presentation with a brief background of the patient’s condition to understand the foundations of the care plan.  

Background Scenario 

Our patient is a 65-year-old man with CHF who lives in a rural neighborhood, which limits his access to specialized cardiac care. His medical history includes hypertension, and currently, he is presenting shortness of breath (SOB), fatigue, and peripheral edema. His primary healthcare physician, Dr. Johnson, is striving to provide comprehensive care to our patient in remote settings; thus, he collaborated with a team of healthcare providers, including a cardiologist, a registered nurse, and a pharmacist. This interdisciplinary team has kept forward some recommendations for an evidence-based care plan that includes pharmacological interventions, telemonitoring, and patient education on medication adherence. My evidence-based care plan combines these three health interventions along with cardiac rehabilitation and home health services to deliver holistic remote care. 

Evidence-based Care Plan 

Pharmacological Interventions

Medications, including ACE inhibitors, beta-blockers, and diuretics, are essential in managing CHF. These medications improve heart function, reduce symptoms, and decrease hospitalizations. ACE inhibitors and beta-blockers are effective for cardiac patients in lowering their blood pressure, reducing cardiac workload, and improving heart outcomes (Strauss et al., 2021). On the other hand, diuretics can significantly manage symptoms of CHF, such as edema and shortness of breath, by maintaining euvolemia and alleviating fluid retention (Magdy et al., 2022). These medications collectively enhance the patient’s quality of life and long-term outcomes by optimizing cardiovascular health and minimizing complications, thus improving health and safety outcomes. 

Telemonitoring

According to the literature, telemonitoring for CHF patients involves remotely reviewing patients’ vital signs through blood pressure monitor and pulse oximetry. It has also been shown to reduce hospital readmission rates by 24% and 27% in 6-month and 12-month periods, respectively (Ramgobin et al., 2022). Daily tracking of vital signs allows for early detection of exacerbations, facilitating prompt interventions. Furthermore, regular virtual consultations ensure consistent follow-up, enhancing adherence to treatment and empowering patients through active participation in their health management.

Patient Education on Medication Adherence

Medication non-adherence is a significant cause of morbidity and mortality among heart failure patients. Thus, educational interventions are crucial in increasing awareness related to the importance of therapeutic regimens (Jarrah et al., 2023). Educating patients about their medications, potential side effects, and the importance of adherence decreases hospitalizations and poor outcomes. Reminders through follow-up calls and physical sessions in community centers can enhance adherence, fostering self-management behaviors and improving overall health (Jarrah et al., 2023). 

Cardiac Rehabilitation

Cardiac rehabilitation programs, including exercise training and education, significantly benefit CHF patients by improving quality of life, cardiac function, patient performance, and CHF-related hospitalizations and mortality (Bozkurt et al., 2021). Structured exercise regimens enhance physical fitness without overexertion, while educational components provide insights into heart-healthy behaviors and disease management. By promoting holistic care, cardiac rehabilitation enhances both physical and mental well-being, leading to improved patient outcomes and reduced healthcare costs.

Lifestyle Modifications

Lifestyle modifications play a crucial role in managing CHF. Ghodeshwar (2023) mentions that a heart-healthy diet, low in sodium and rich in potassium, including anti-inflammatory food, helps control blood pressure and reduce systemic inflammation, promoting cardiovascular health. Similarly, incorporating regular physical activity improves cardiovascular fitness and reduces the risk factors for cardiac exacerbations such as obesity (Ghodeshwar, 2023). Thus, lifestyle changes contribute to improved outcomes and reduced hospitalizations for CHF patients. 

However, more information on the patient’s specific comorbidities, socioeconomic status, and support system would enhance the care plan’s effectiveness. Data on the patient’s current dietary habits, physical activity level, and access to healthcare resources in the rural setting are crucial for tailoring interventions. Additionally, insights into the patient’s psychological state and health literacy would inform personalized education strategies and support mechanisms, ensuring comprehensive and patient-centered care.

Evidence-Based Practice Model

This evidence-based care plan is grounded in the evidence-based practice (EBP) model for a structured approach to the plan, offering only credible and relevant research-based interventions for CHF patients. I employed the Johns Hopkins Evidence-Based Practice (JHEBP) Model, which is a structured approach to integrate evidence for clinical decision-making. It involves three key steps: identifying a practice question, gathering the best available evidence to answer it, and translating that evidence into practical interventions to improve patient care and outcomes (Dusin et al., 2023). The model was utilized as follows: 

1. Identify the Practice Question: In developing this remote care evidence-based plan, the identified practice question was: “What are the most effective interventions to improve health and safety for a 65-year-old male with congestive heart failure in remote care settings?” This question focuses on optimizing patient outcomes through specific interventions tailored to CHF patients in underserved areas. 
2. Identify the Best Evidence to Answer the Question: To answer this question, I reviewed current research and guidelines on CHF management to find the best practices recommended by the literature, including medication management, remote monitoring, patient education, cardiac rehabilitation, and lifestyle changes. I then performed a rigorous search for evidence in credible databases, including evidence from authoritative sources like clinical trials, systematic reviews, and practice guidelines. 
3. Translate the Evidence to Practice: The final step involves the translation of the information into practice by integrating it into a comprehensive care plan (Dusin et al., 2023). This involved outlining specific interventions supported by the literature. We aim to implement this plan in remote care settings by involving a multidisciplinary team to enhance patient care and outcomes.

NURS FPX 4030 Assessment 4 Remote Collaboration and Evidence Based Care

The objective of this care plan is to result in several benefits for our patients, including symptomatic management, reduced hospital readmissions, enhanced quality of life, improved medication adherence, and enhanced cardiovascular health. Therefore, it is crucial to evaluate these benefits through various evaluation methods. Initially, we aim to perform a pre- and post-intervention assessment that includes monitoring of metrics like hospital readmission rates, symptom severity scales, and adherence rates to medications. Secondly, we will monitor patient-reported outcomes such as quality of life and satisfaction through surveys, providing valuable insights into the patient’s experience and perceived improvements (Churruca et al., 2021). Finally, analyzing data trends from telemonitoring devices can reveal vital signs improvement and symptom management. Combining these methods allows for a comprehensive evaluation of how effectively the care plan enhances patient outcomes and identifies areas for further improvement.

Relevant and Useful Evidence 

The most relevant and helpful evidence used to establish this care plan is the article that explains the importance of telemonitoring in CHF patients. Telemonitoring stands out as the best intervention for a CHF patient in remote care as it enables real-time monitoring of vital signs, allowing for early detection of symptoms and prompt intervention. I employed the CRAAP criteria to assess the relevance and credibility of the selected resource. The requirements include Currency (up-to-date information), Relevance (relevant to practice question), Authority (authors and publisher are credible), Accuracy (information is accurate without any biases), and Purpose (purpose of the study matches the intent of the researcher) (Esparrago-Kalidas, 2021). 

The study by Ramgobin et al. (2022) meets all these aspects, offering valuable insights into the benefits of telemonitoring for CHF patients that include reduced hospital readmission rates (by 24% and 27%), which is one of the significant negative consequences of heart failure, resulting in poor patient outcomes and increased healthcare costs. Additionally, this article underscores the importance of ongoing care for patients in remote areas with limited access to specialized care pertinent to our patient’s case. Ramgobin et al. (2022) present that telemonitoring bridges the gap, offering critical health insights and personalized care adjustments without the need for frequent in-person visits, enhancing patient safety and overall management of CHF. Therefore, this resource is highlighted as the most relevant and helpful in making this evidence-based care plan. 

Interdisciplinary Collaboration – Benefits and Challenges

Finally, we are at the last part of our presentation, which covers the benefits and challenges associated with interdisciplinary collaboration in remote care teams. 

Benefits of Interdisciplinary Collaboration

Interdisciplinary coordination in remote care teams offers various benefits, such as augmenting patient outcomes through a holistic approach to care. By integrating diverse expertise, such as doctors, nurses, pharmacists, and community health workers, teams can provide comprehensive care by addressing multiple health issues. This collaboration improves communication, reducing medical errors and improving patient safety. Furthermore, this cooperation increases care coordination and enhances healthcare accessibility for patients in underserved areas (Bendowska & Baum, 2023). 

Challenges of Interdisciplinary Collaboration 

However, these teams may face a few challenges in remote areas. These include communication barriers and role clarity conflicts. It is essential to implement standardized communication protocols and use reliable, user-friendly technology platforms for regular updates and virtual meetings. Moreover, clear guidelines for communication frequency and methods should be established to ensure all team members stay informed and engaged (Sheehan et al., 2021). Similarly, to avoid conflicts, clearly define each team member’s roles and responsibilities at the outset and ensure everyone understands their contributions to the care plan. Regularly review and adjust roles as needed to address any emerging issues and maintain a collaborative environment.

To better leverage interdisciplinary collaboration in future remote care, teams should foster a shared understanding among team members and encourage continuous professional development to optimize their collective expertise. Emphasizing joint decision-making will ensure a more comprehensive approach to patient care (Hsiao et al., 2022). Additionally, implementing feedback mechanisms and evaluating outcomes regularly can help refine collaborative practices, leading to more effective management of chronic conditions and improved patient outcomes in remote settings.

Conclusion

In conclusion, remote collaboration has become a pivotal aspect of healthcare for patients living in rural areas, like our patient with CHF. Limited access to specialized care and geographical barriers have impacted his health outcomes; thus, our evidence-based care plan addresses these challenges through pharmacological interventions, telemonitoring, patient education, cardiac rehabilitation, and lifestyle modifications. We aim to implement this plan through interdisciplinary collaboration among his primary care physician, a cardiologist, a nurse, and a pharmacist. However, several challenges may arise, such as communication barriers and role conflicts within the care team. To mitigate those challenges, communication protocols, and role clarity are essential to enhance coordination and deliver comprehensive care. These strategies aim to improve patient outcomes, reduce hospital readmissions, and elevate the overall quality of life.

References

Bendowska, A., & Baum, E. (2023). The significance of cooperation in interdisciplinary health care teams as perceived by Polish medical students. International Journal of Environmental Research and Public Health, 20(2). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9859360/ 

Bozkurt, B., Fonarow, G. C., Goldberg, L. R., Guglin, M., Josephson, R. A., Forman, D. E., Lin, G., Lindenfeld, J., O’Connor, C., Panjrath, G., Piña, I. L., Shah, T., Sinha, S. S., & Wolfel, E. (2021). Cardiac rehabilitation for patients with heart failure. Journal of the American College of Cardiology, 77(11), 1454–1469. https://doi.org/10.1016/j.jacc.2021.01.030

NURS FPX 4030 Assessment 4 Remote Collaboration and Evidence Based Care

Churruca, K., Pomare, C., Ellis, L. A., Long, J. C., Henderson, S. B., Murphy, L. E. D., Leahy, C. J., & Braithwaite, J. (2021). Patient‐reported outcome measures (PROMS): A review of generic and condition‐specific measures and a discussion of trends and issues. Health Expectations : An International Journal of Public Participation in Health Care and Health Policy, 24(4), 1015–1024. https://doi.org/10.1111/hex.13254 

Dusin, J., Melanson, A., & Mische-Lawson, L. (2023). Evidence-based practice models and frameworks in the healthcare setting: A scoping review. BMJ Open, 13(5), e071188. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10230988/ 

Esparrago-Kalidas, A. J. (2021). The effectiveness of CRAAP test in evaluating credibility of sources. International Journal of TESOL & Education, 1(2), 1–14. https://i-jte.org/index.php/journal/article/view/25 

Ghodeshwar, G. K. (2023). Impact of lifestyle modifications on cardiovascular health: A narrative review. Cureus, 15(7). https://doi.org/10.7759/cureus.42616

Hsiao, C.-Y., Wu, J.-C., Lin, P.-C., Yang, P.-Y., Liao, F., Guo, S.-L., & Hou, W.-H. (2022). Effectiveness of interprofessional shared decision-making training: A mixed-method study. Patient Education and Counseling, 105(11). https://doi.org/10.1016/j.pec.2022.07.010 

Jarrah, M., Khader, Y., Alkouri, O., Al-Bashaireh, A., Alhalaiqa, F., Al Marzouqi, A., Qaladi, O. A., Alharbi, A., Alshahrani, Y. M., Alqarni, A. S., & Oweis, A. (2023). Medication adherence and its influencing factors among patients with heart failure: A cross sectional study. Medicina (Kaunas, Lithuania), 59(5), 960. https://doi.org/10.3390/medicina59050960 

Magdy, J. S., McVeigh, J., & Indraratna, P. (2022). Diuretics in the management of chronic heart failure: When and how. Australian Prescriber, 45(6), 200–204. https://doi.org/10.18773/austprescr.2022.069

Ramgobin, D., Vo, M., Golamari, R., Jain, R., & Jain, R. (2022). Congestive heart failure clinics and telemedicine: The key to reducing hospital readmissions in the United States. Cardiology Journal, 0(0). https://doi.org/10.5603/CJ.a2021.0073

NURS FPX 4030 Assessment 4 Remote Collaboration and Evidence Based Care

Sheehan, J., Laver, K., Bhopti, A., Rahja, M., Usherwood, T., Clemson, L., & Lannin, N. A. (2021). Methods and effectiveness of communication between hospital allied health and primary care practitioners: A systematic narrative review. Journal of Multidisciplinary Healthcare, 14(14), 493–511. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7910528/ 

Strauss, M. H., Hall, A. S., & Narkiewicz, K. (2021). The combination of beta-blockers and ACE inhibitors across the spectrum of cardiovascular diseases. Cardiovascular Drugs and Therapy, 37(4). https://doi.org/10.1007/s10557-021-07248-1