NURS FPX 6030 Assessment 6 Final Project Submission

Name

Capella university

NURS-FPX 6030 MSN Practicum and Capstone

Prof. Name

Date

Abstract

Chronic Heart Failure (CHF) is the inability of the cardiac muscle to circulate sufficient blood throughout the body to provide adequate oxygen supply. This capstone project is based on providing personalized self-management support through education, care coordination, and medication management for adult CHF patients. The study will be conducted over six months with adult chronic care patients with heart failure. The primary focus was to enhance adult CHF patient outcomes and healthcare quality. The findings indicated that self-care education and medication management improve adult patients’ quality of life. Adult patients who receive coordinated care and support for self-management experience significant improvements in their health, leading to a better quality of life and well-being.

Moreover, medication management and education significantly reduce adverse events. Integration of telehealth services facilitates the quality improvement of adult CHF patients. Incorporation of stakeholders’ perspectives, federal organizations’ policies, and guidelines and consideration of ethical issues assist in the intervention plan. opinions. The evidence-based results showed that medical professionals can care for adult CHF patients with self-management, care coordination, and medication management interventions, resulting in reduced hospital readmissions and adverse events. 

Introduction

The major goal of this capstone project is to address the complicated demands of adult chronic care patients suffering heart failure in outpatient clinics. CHF is a prevalent and challenging condition causing breathing issues, fatigue, and congestion in patients (Koshy et al., 2020). High mortality rates, poor living standards, and significant financial and resource strain on healthcare systems characterize the issue. Every year, 1 million people become hospitalized with an initial prognosis of CHF, resulting in a total Medicare expenditure of more than $17 billion in the United States (Faragli et al., 2021).

The CHF is a serious health issue that harms an individual’s standard of life. The capstone project will be conducted in adult CHF patients within outpatient clinics. The capstone project aims to target adult patients with CHF, a population with high hospitalization rates and complex healthcare needs. The group is significantly impacted by issues with self-management, which results in hospital readmissions (Leavitt et al., 2020). 

NURS FPX 6030 Assessment 6 Final Project Submission

The intervention strategy for adult CHF patients in outpatient clinics is a comprehensive approach that includes self-management education, periodic care coordination, and precise medication management (Griffin et al., 2019). The initiative aims to improve self-care behaviors in CHF patients through personalized self-management education, promoting medication adherence, symptom detection, and lifestyle modifications (Jaarsma et al., 2021). Effective communication and coordination between medical staff and patients are crucial for coordinated care, managing complex treatment strategies, and reducing hospital visits for adult CHF patients. (Koutlas & Jenkins, 2022).  

Coordinated care strategies, which include frequent examinations and patient training, are intended to minimize complications and enhance CHF patients’ overall health significantly (Bhaskar et al., 2020). Medication management is crucial in ensuring compliance with medications reducing readmissions and adverse drug events in CHF patients (Zazzara et al., 2021). The urgency to reduce the suffering and low standard of life experienced by adult CHF patients necessitates the adoption of an intervention strategy. Adult CHF patients face daily challenges such as persistent nervousness and anxiety, as well as an increased likelihood of psychological issues (Butler et al., 2023). Incorporating self-care, integrated care, and medication management promotes the standard of life while providing evidence-based guidelines to enhance adult CHF patients’ health outcomes (Griffin et al., 2019).

NURS FPX 6030 Assessment 6 Final Project Submission

The intervention plan, involving multidisciplinary collaboration among nurses, medical professionals, nutritionists, health educators, and administrators, focuses on efficiently implementing interventions in the medical care system. Incorporating nursing care models, federal legislation, and leadership strategies enhances patient outcomes by promoting coordination and teamwork among medical professionals. Self-management education and training for CHF patients and medical professionals improve their knowledge and understanding of interventions (Zhao et al., 2020).

The evaluation strategy will measure the intervention’s outcomes over six months. The evaluation plan assesses the intervention’s impact on adult CHF patients’ health by monitoring parameters like blood pressure and heart rate changes and assessing admission and hospitalization rates (Son et al., 2020). The survey method will be employed to collect feedback and questionnaire information to assess the intervention’s success. Pre- and post-tests can be conducted to assess the improvement in knowledge, understanding, and perspectives toward drugs and self-management in an outpatient setting for individuals with CHF (Santos et al., 2021).

Evaluation of the Best Available Evidence

A comprehensive literature search was conducted across different databases, including EBSCO, Medline, CINAHL,  PubMed, and Science Direct, to evaluate the intervention (Pedroni et al., 2023). The research focused on the impact of self-care and medication adherence on life standards, healthcare costs, and hospitalization rates. The evidence suggests that combining self-management, medication management, and coordinated care interventions can significantly improve the quality of life for adult CHF patients (Pedroni et al., 2023).

Problem Statement (PICOT)

Need Statement

Adults suffering from CHF have serious repercussions, highlighting the crucial demand for intervention for health promotion (Takeda et al., 2019). This capstone project aims to improve patient outcomes and quality of life for adult chronic care patients with CHF in outpatient clinics by creating and implementing an intricate strategy. CHF patients experience psychological and physical symptoms like shortness of breath, fatigue, inflammation, insomnia, and anxiety. It hinders their daily social and physical engagement, leading to an inadequate standard of life (Costa et al., 2020). The critical need is to develop an integrated intervention approach that includes tailored self-management assistance, coordinated care, and standard drug management.

The complexity of CHF patient management necessitates intervention, as successful outcomes depend on effective medicine and patient competency in managing disease through lifestyle adjustments and indicators monitoring (Dunlay et al., 2019). CHF patients face high hospitalization rates and low quality of life due to insufficient self-management and lack of integrated treatment. Around 24% of heart failure patients are readmitted within 1 month of hospital discharge, highlighting the need for enhanced care after discharge and self-management assistance. (Leavitt et al., 2020). 

NURS FPX 6030 Assessment 6 Final Project Submission

Schumacher et al. (2021), reported that improved medication adherence and management have been proven to reduce hospital stays and mortality rates. To improve outcomes, multidisciplinary and integrated coordinated care approaches assist CHF patients in regularly managing drugs. Research by Jaarsma et al. (2021), highlighted that medication adherence and self-care are critical in the ongoing care of CHF. The Heart Failure Association’s (HFA) CHF guidelines emphasize patient awareness of treatment adherence, lifestyle adjustment, illness monitoring, and proper response to possible aggravation. In patients with CHF, self-care is associated with professional and personalized outcomes, including enhanced standards of life and reduced death and hospitalization rates. 

Heidenreich et al. (2022), reported that the cost of CHF care is significant because of the substantial expenses of hospitalization and persistent therapy. The average yearly expense of treating CHF in the United States is approximately $30,000. This evidence emphasizes the financial strain related to CHF, implying that CHF must be managed to avoid economic crises. The capstone project focuses on improving the standard of life and reducing CHF outcomes in adult patients by targeting the demand for suitable therapies. Employing evidence-based strategies to address the health concerns of adult CHF patients (Dessie et al., 2021).

Population and Setting

This project’s target population is adult patients with CHF, a population who have elevated rates of hospitalizations and intricate medical care demands. The elderly population is most severely impacted by difficulties in self-management, which frequently leads to hospital stays. Adult CHF patients often have associated illnesses like high blood pressure and diabetes, complicating their care management further. Addressing this requirement is crucial for their well-being (Dunlay et al., 2019). Research by Schumacher et al. (2021), showed that The intricacy, multimorbidity, and diversity of heart failure raise the risk of pharmaceutical noncompliance, patient misunderstanding, and severe side effects.

Medication noncompliance, drug reactions, contraindications, duplicating drugs, and challenging side effects are the primary causes of CHF aggravation. Medication management is crucial, along with regular coordinated care, to improve patient safety. Research showed a 22% drop in readmission rates due to improved medication management at discharge (Agostinho et al., 2019).

NURS FPX 6030 Assessment 6 Final Project Submission

The capstone project’s target setting is outpatient clinics concentrated on CHF care. The setting was chosen because it offers a continuous healthcare system where patients receive periodic evaluations, education, counseling, and assistance. Outpatient clinics are critical for implementing self-care education, drug management, and coordinated care because they enable immediate and persistent patient-caregiver interaction (Halatchev et al., 2020). A comprehensive treatment model that reduced the frequency of readmission and medical expenses by 35%, demonstrating the approach’s overall efficacy and effectiveness for controlling CHF in outpatient clinics (Olson et al., 2023). This evidence is pertinent, current, adequate, and reliable, offering a firm basis for the proposed intervention.

Several other researchers have found that outpatient settings checkups and coordinated treatment can assist in reducing the incidence of readmissions in CHF patients. However, managing this group in an outpatient setting offers barriers, such as varied health knowledge among CHF patients, impacting their competency to comply with self-management guidelines and reluctance to perform regular surveillance visits (Friis et al., 2019). Adult CHF patients can acquire integrated and holistic care through a coordinated and multidisciplinary approach (Olson et al., 2023).

Intervention Overview

A multifaceted, comprehensive care intervention plan that includes tailored self-management education, regular care coordination, and accurate drug management is advocated for adult CHF patients in outpatient settings. These components deal with the issues of this patient population in the outpatient clinic. Individualized self-care education is crucial because it assists patients with the understanding and abilities they need to manage their disease effectively (Griffin et al., 2019).

According to D’Souza et al. (2021), individualized self-management awareness and education can enhance self-care practices in CHF patients. This educational program involves instruction in compliance with medications, symptom identification, and lifestyle modifications. Still, the problems lie in tailoring instruction due to different patient comprehension and health conditions and a possible significant resource required for individualized training.

NURS FPX 6030 Assessment 6 Final Project Submission

Continuous care coordination enhances interaction among medical professionals, resulting in integrated and adaptive care regimens (Koutlas & Jenkins, 2022). Collaborative and coordinated care efficiently minimizes hospital admissions in CHF patients. This cooperation is critical in managing these patients’ complicated medication and care strategies (Zhao et al., 2021). Besides positive impact, a few barriers are crucial, including significant communication gaps among medical professionals and the incorporation of intervention strategies into existing medical systems.

Meticulous medication management is vital for the intricacy of multiple drugs in CHF management, and medication management intervention focuses on patients’ comprehension and adherence to their prescription schedules precisely (Lum et al., 2020). Griffin et al. (2019), revealed that effective drug management is linked to improved CHF patient outcomes and quality of life. Although this intervention has shown better outcomes, there is a knowledge gap about the effectiveness of these interventions for CHF patients having low health knowledge and intellectual disabilities. It is vital to ensure ongoing CHF patient education and monitoring (D’Souza et al., 2021).

Comparison of Approaches

Alternative strategies like telehealth and interdisciplinary collaboration can enhance quality and health promotion in outpatient settings for CHF patients. Interdisciplinary teams contain specialists, like dietitians, psychiatrists, and fitness physiologists. Engaging diverse professionals in CHF care ensures a comprehensive approach to patient well-being, including nutrition, psychological wellness, and physical activity (Ee et al., 2020). Passantino et al. (2021), asserted that exercise-based Cardiac Rehabilitation (CR) positively influences the lowering of hospital admissions and death in CHF patients.

Exercise-based CR enhances endurance and quality of life in patients with CHF, thereby preventing CHF development (Chun & Kang, 2021). While psychological assistance can effectively address the psychological challenges linked to heart failure, which are often overlooked in conventional care methods. Studies reveal that CHF patients often experience psychological health issues, leading to inadequate self-care and reduced quality of life. Psychological intervention positively impacts the emotional and mental well-being of CHF patients (Hirani et al., 2022). 

NURS FPX 6030 Assessment 6 Final Project Submission

Telehealth services provide remote surveillance and assistance, benefiting patients with mobility challenges or those living in remote areas. A study by Srivastava et al. (2019), demonstrated that telehealth procedures can significantly reduce CHF-related death and hospitalization rates. This strategy fosters interdisciplinary collaboration by allowing remote participation of specialists, broadening the range of treatments available to patients. The integration of telehealth and assistance services requiring collaboration between patients and medical staff offers a approach (Ee et al., 2020). While, telehealth necessitates a stable technological framework and patient digital competence. The involvement of numerous specialists can lead to collaboration issues and stress for patients due to their complicated schedules and multiple appointments (Fedson & Bozkurt, 2022).

Initial Outcome

Implementing sel management assistance, coordinated care, and medication management intervention for adult CHF patients aims to promote well-being and standard of life through education and comprehensive care (Friis et al., 2019). The self-management education strategy personalized to adult CHF patients in outpatient clinics is effective for a 20% decrease in the frequency of 30-day hospital readmission. This specific outcome is consistent with the project’s goal of improving CHF management. The self-care education intervention offers patients with CHF understanding, expertise, and abilities to manage CHF symptoms and increase resilience, enhancing patient safety (Koshy et al., 2020).

Intervention outcomes are crucial as they directly indicate the intervention’s effectiveness in enhancing patient self-care competencies and improving medical coordination. Coordinated care strategies, reduced complications, and enhanced CHF patients’ well-being through periodic check-ups and patient education (Halatchev et al., 2020). 

The drop in readmissions reflects more excellent patient health and financial strain on the medical system, which aligns with the broader goal of healthcare quality improvement (Griffin et al., 2019). Complications accompany CHF, and CHF patients struggle to manage extensive medication regimens. The medication management intervention strives to mitigate the severe effects of CHF and comorbidities in individuals. Medication management can reduce complications and severe CHF conditions by enhancing compliance and patient perceptions, thereby improving the outcomes of CHF patients. The major purpose of the intervention plan is to mitigate health problems (Lum et al., 2020). 

Time Estimate

The estimated time for the successful intervention is six months. A comprehensive and practical schedule is critical for the creation and execution of the intervention addressing adult CHF patients in outpatient clinics. The development period, which includes preparing, allocating, and developing intervention resources, lasts around four months. This step involves designing personalized educational materials, developing care coordination standards, and formulating drug management protocols. The intervention’s complexity warrants a reasonable time frame, provided sufficient resources and stakeholder collaboration are available. This phase can face challenges such as delays in funding collection, communication with healthcare specialists, and customizing training materials to patient needs.

The six-month implementation stage involves progressively introducing intervention components, monitoring initial patient reactions, and making adjustments based on feedback (Santos et al., 2021). The implementation period of six months is sufficient to assess the immediate impact on patient outcomes and well-being, including readmission rates. However, this period can be impacted by obstacles like patient adherence, coordinated care among medical providers, and efficient execution of the intervention into current clinical procedures. Patients’ diverse medical knowledge and involvement levels can lead to additional challenges, necessitating constant adjustment to the intervention method. The estimated time for interventions is six months, but potential long-term effects must be considered. Research is needed to evaluate the long-term benefits of therapies in CHF patients beyond the initial 6-month period (Takeda et al., 2019).

Literature Review

CHF has become a worldwide pandemic, impacting over 64 million individuals globally and costing the $346.17 billion in disease expenses. Although the majority of expenditure is for hospital admissions for aggravated CHF. Adequate self-management can avert roughly 40% of occasions of CHF (Yu et al., 2022). CHF-linked self-care is an evolving cognitive-behavioral procedures designed to maintain health by compliance to medication and self-care support, symptom awareness, and precise assessment. It also involves action regarding warning signs of disease worsening by self-care management, improving patient safety. Because increasing research suggests that efficient self-care plays a role in influencing patient health outcomes, more recent globally CHF management recommendations argue for self-care as a critical therapy to supplement pharmaceutical care (Yu et al., 2022). 

Self-management awareness and education programs, according to Salahodinkolah et al. (2020), strengthen CHF patients’ dedication to self-care protocols and managing their medications, resulting in reduced hospital visits and improved patient safety. It has been discovered that having adequate health-related information is an effective approach for minimizing future medical issues and increasing general health. It also assists in the prevention of disease (Sun et al., 2019). The research demonstrating the intervention’s suitability for the target demographic is significant. According to Powell et al. (2022), the worldwide focus is on enhancing drug management, there are still gaps in the healthcare system when patients with CHF are treated in outpatient clinics.

NURS FPX 6030 Assessment 6 Final Project Submission

Patients who do not receive adequate treatment can experience worsened symptoms, lower standards of life, and an increase in death rate. Improper medication management could result to unnecessary hospitalizations and immediate admissions, with CHF accounting for 5% of patients stays in hospitals. When adults undergo care transitions, communication about drug management can be difficult. Communication problems can lead to medication errors or mishaps. Ozavci et al. (2021), emphasized that improving communication and multidisciplinary cooperation promotes drug reconciliation, lowering disparities and mistakes regarding medicine, and enhancing medicine management.

Adult patients with complex medical conditions are at higher danger of noncompliance with their medications. According to Yang et al. (2021), approximately 55% of CHF patients had multiple illnesses. Assistance with self-management has been recognized as a successful approach for improving drug adherence in individuals with CHF. A medication self-management strategy combines several elements with the goal of assisting patients to take medications safely and efficiently. It is possible through such as changing health behaviors and patient awareness. Research by Alsulymani et al. (2023), reveals an important discrepancy in CHF management.

NURS FPX 6030 Assessment 6 Final Project Submission

Approximately 80% of patients require hospitalization within 90 days of discharge. The significant frequency of readmission confirms the necessity for an intervention that tackles post-discharge care and management inadequacies. The convincing data supports the vital requirement for an extensive care strategy in CHF, particularly in outpatient settings. According to Kripalani et al. (2019),  multi-component strategy administered by nurses like coordinated care reduces 30 or 90-day hospitalization as well as associated Medical expenses.

Multiple factors complicate care for the adult vulnerable population, such as, late diagnosis, complicated medical profiles, dispersed treatment, and an absence of prompt access to medical resources. Patient engagement outside clinic has many significant benefits in chronic CHF care, according to Kao et al. (2020), including possibilities for patient evaluation, early detection of decline, recognizing challenges to treatment, and training to empower CHF patients with self-management.  Telemonitoring is crucial for remote self management education. It has significant impact on the effectiveness of interventions.

Telemonitoring allows medical professionals to remotely assist outpatients in self-managing CHF medication (Ding et al., 2019). Each research offers a new perspective, helping to establish a strong argument for the need and appropriateness of an integrated care approach in the management of CHF patients in outpatient clinics. This comprehensive review guarantees that the intervention is based on evidence, improving its chances of success in the intended demographic and setting.

Intervention Plan

Intervention Plan Components

The intervention plan intends to improve the standard of life of adult CHF patients through several intervention modalities. The intervention focuses on creating a comprehensive care model through individualized self-management education, care coordination, and medication management (Butler et al., 2023). The intervention strategy focuses on critical requirements for CHF patients’ health promotion. Self-management initiatives can minimize readmissions of CHF patients, improve self-care competency, and improve their daily life (Dunlay et al., 2019). The intervention plan incorporates coordinated care strategies, which are critical in reducing CHF-related complications. It improves the well-being of people with CHF (Zhao et al., 2021). The integration of adequate medication management can reduce hospitalizations and fatalities by managing drug interactions and adverse events and enhancing patient safety (Schumacher et al., 2021).

Self-care training procedures enhance compliance with self-care protocols and medication management in CHF patients, reducing hospital readmissions and improving quality of life (Dunlay et al., 2019). Understanding the causes of illness is a crucial strategy for reducing future health issues and preventing future ones (Koshy et al., 2020).  The intervention plan successfully improves patient health and reduces CHF complications, focusing on quality of life (Dessie et al., 2021). The intervention approach is based on the assumption that the adult CHF population is firmly ingrained in their cultural beliefs. It also presumes that including cultural factors in interventions improves results. The emphasis should also be on clinically proven, evidence-based CHF therapy (Riegel et al., 2021).

Impact of Cultural Needs on the Intervention

Cultural beliefs significantly influence health-related thoughts, medication choices, and treatment selection of adult CHF patients. It necessitates an integrated intervention plan that aligns with their values (Hill et al., 2023). CHF patients’ cultures vary significantly, influencing their understanding of the condition and ability to adjust and execute treatment options (Riegel et al., 2021). Cultural considerations influence patients’ self-care habits, necessitating encouragement or provision of necessary knowledge and abilities for patients from diverse cultures (Nair & Adetayo, 2019). Cultural competence is essential for individualized care because it allows healthcare workers to deliver efficient, culturally competent therapy.

Considering and understanding the views and perspectives of diverse communities patients towards care management, aids in the effectivness of intervention plan (Hill et al., 2023). Cultural consideration involves incorporating cultural practices, customs, and faiths into treatment, considering their impact on assistance-seeking behaviors, self-care perceptions, and medication choices (Riegel et al., 2021). Cultural sensitivity in intervention plans increases active participation, minimizes stigma, and enhances effectiveness by fostering treatment acceptance (Nair & Adetayo, 2019). 

Theoretical Foundations of Nursing Models, Discipline Strategies, and Technology

For an intervention plan to be effective, it must include suitable nursing models, tactics from other disciplines, and medical care-related technologies. The Health Belief Model (HBM) applies to initiatives to improve quality and prevent complications. The treatment plan anticipates self-management behaviors like drug adherence by employing an HBM structure for examining health-related activities (Habibzadeh et al., 2021). Patients’ belief in health issues and interventions is crucial for HBM, as it influences health-related activities and positively influences readmission preventive behaviors.

However, the HBM excludes societal attitudes and practices that impact compliance with healthcare guidelines (Habibzadeh et al., 2021). Orem’s Self-Care Model has significance in the effectiveness of the intervention plan. This framework highlights the adults’ autonomy, enabling them to be engaged in their wellness maintenance. It can improve CHF patients’ independence and effective self-management. This model only applies to some CHF patients, particularly those with severe medical conditions requiring extensive treatment (Khademian et al., 2020).

NURS FPX 6030 Assessment 6 Final Project Submission

Strategies from different disciplines can also be effective in developing a holistic intervention strategy for adult CHF patients. Cultural competence education aids healthcare providers in understanding their patients’ cultural norms, enabling them to tailor treatments to their specific needs. However, a culturally sensitive strategy takes longer and requires more significant assets (Nair & Adetayo, 2019). Nutritional intervention can improve the outcomes of CHF patients, aiding in the reduction of hospital readmission. Dietitians recommend the Dietary Approaches to Stop Hypertension (DASH) diet to prevent heart failure and improve CHF patients’ health outcomes. However, studies demonstrate that the DASH diet has modest benefits in managing heart failure (Goyal et al., 2021).

 Telehealth services provide remote surveillance and support to patients with geographical issues, reducing hospitalizations in CHF patients (Srivastava et al., 2019). Telehealth services significantly improve the quality of life for CHF patients by educating them about self-care, medication management, and symptom tracking (Guo et al., 2019). Moreover, telehealth requires a technical structure, patient digital awareness, and multiple doctors’ engagement, which can cause coordination challenges and stress due to convoluted schedules and consultations (Guo et al., 2019).

Justification of the Components of the Intervention

Bhaskar et al. (2020), highlighted the effectiveness of coordinated care. Coordination and teamwork are critical in managing adult CHF patients’ extensive treatment regimens and analyzing their needs, resulting in fewer hospital visits. Comprehensive care coordination necessitates excellent collaboration between healthcare workers and patients to ensure holistic and adaptive treatment options. Self-management education and the nursing care model are effective interventions to reduce the hospital readmissions of adult CHF patients.

According to Mohebbi et al. (2019), research, HBM can be used to develop educational programs for CHF patients. As a result, this framework can be utilized to efficiently avoid associated complications of heart failure, lowering fatality and hospital readmissions. Nasiri et al. (2023), asserted that educational programs based on Orem’s Nursing Theory have been increasingly used to guide practice for patients with chronic health issues, enhancing their standard of life and self-management. Studies have shown that medication compliance and management are critical to improving patient outcomes and sustaining health in hospitals and outpatient clinics. According to studies, a large proportion of patients with CHF who were previously re-hospitalized can prevent re-admission if they adhere to their comprehensive care plan and medication maintenance (D’Souza et al., 2021). 

Stakeholders, Policy, and Regulations

Stakeholders play a crucial role in healthcare planning, enhancing the intervention plan to improve the quality of life for CHF patients. The intervention plan involves stakeholders such as patients, families, health workers, and executives (Kumari et al., 2020). These stakeholders reported diverse requirements and preferences for CHF patient management techniques. Patients’ and families’ opinions and issues impact the safety and efficacy of interventions. Healthcare professionals require realistic guidelines, sufficient education, and regular feedback for effective interventions (Riegel et al., 2021). Considering these factors is crucial since it influences the practicability, legitimacy, and effectiveness of the intervention.

Healthcare policies significantly impact resource availability, intervention implementation, reimbursement mechanisms, financial feasibility, and of CHF patients’ interventions. The Disease Management Programs (DMPs) policy has a significant effect on improving the management of CHF patients. It contributes to an improved standard of life and patient security. DMPs enhance patient outcomes through systematic monitoring, patient awareness, healthcare improvement, psychological aid, and improved care opportunities. DMP policies significantly reduce hospitalizations and medical costs, boosting treatment and medication adherence while consuming fewer resources (Kalogirou et al., 2020). 

The Heart Failure Society of America (HFSA) sets guidelines, such as comprehensive education and support customized to individual patients’ requirements. The regimen also promotes self-care and medication management by the patient (Greene et al., 2021). Furthermore, the HFSA proposed improving compliance through cognitive approaches, maximizing health care, extending the availability of specialists, and addressing socioeconomic difficulties. HFSA provides an accurate, comprehensive approach to starting and running a CHF clinic. The guidelines outline patient care decisions, operational considerations, leadership assistance, nursing staff models, and quality enhancement (Greene et al., 2021).

Ethical and Legal Implications

Intervention plans must consider legal and moral implications to avoid ethical issues and maintain patient privacy while adhering to principles like autonomy, beneficence, and nonmaleficence (Desai & Kapadia, 2022). Following ethical norms, including Health Insurance Portability and Accountability Act (HIPAA) regulations, is crucial for maintaining patient confidentiality, anonymity, and secrecy in healthcare delivery interventions, necessitating robust security measures (Desai & Kapadia, 2022). Health providers should adhere to the principle of autonomy when creating personalized care plans for CHF patients.

Employing appropriate privacy safeguards and taking appropriate steps to avert data breaches improves patient safety (Faget et al., 2021). Telehealth services provide efficient healthcare for CHF patients, enabling intervention programs, but medical practitioners must ensure privacy and compliance with HIPAA rules. HIPAA violations in telehealth services can lead to severe penalties and legal action, necessitating health workers’ training to ensure safe and effective care in remote interventions (Faget et al., 2021).

Implementation Plan

Management and Leadership

Transformational leadership enhances interprofessional collaboration and shared goals among medical personnel in executing intervention strategies for CHF patients. By fostering open discussion and interprofessional teamwork, transformational leaders promote a culture of CHF patient management and improve quality (Sarkies et al., 2020). Transformational leadership fosters cooperation, productivity, and quality care through transdisciplinary education, respect, compassion, and frequent meetings, enhancing team comprehension, collaboration, and problem-solving skills. Quality improvement management solutions for delivering treatments through multidisciplinary teams involve encouraging collaboration, transparency, and feedback (Olson et al., 2023). 

Inter-Professional Collaborative Practice (IPCP) motivates nurses to collaborate with medical staff to address concerns during intervention implementation and enhance the quality of care (Davidson et al., 2022). Ongoing nurse training can incorporate self-care, medication management, and coordinated care interventions while giving updated approaches and effective communication and cooperation skills (Davis et al., 2021). Nurse-led education programs guarantee that patients receive tailored disease management intervention (Davis et al., 2021).

Delivery and Technology

Telehealth technology allows CHF patients to get remote counseling and awareness sessions, eliminating the disparity between healthcare providers and patients and enabling accessible and tailored consultation (Guo et al., 2019). Training seminars and instructional sessions through telehealth can improve self-care knowledge and drug compliance by giving them general health practice expertise from medical professionals. Telehealth and instructional strategies can improve the accessibility and effectiveness of therapies for CHF patients, lowering medical care barriers (Srivastava et al., 2019).

Telemedicine enables faster remote medical treatment delivery for CHF patients, reducing barriers like regional and mobility constraints by enabling virtual communication with providers. However, there can be issues with telemedicine acceptability, such as the probability of computing difficulties or breach of confidentiality (Singhal et al., 2023). Health tracking applications give health data and support, aiding CHF patients in controlling their condition independently. These apps connect patients to various amenities, such as assistance, surveillance equipment, and healthcare guidance (Woods et al., 2019).

Stakeholders, Policy, and Regulations

Adult CHF patients, nurses, and medical professionals are the major stakeholders in the adult CHF patient management intervention strategy. Active participation and stakeholder feedback are critical for the plan’s successful execution (Riegel et al., 2021). Nurses in outpatient clinics play a crucial role in providing coordinated treatment and self-management services for CHF patients. Nurses assist patients during self-care education, monitor their condition and progress, and provide any necessary treatment. To ensure the success of intervention implementation, nurses and other medical professionals must be well-trained (Zhao et al., 2020).

A CHF quality improvement plan with regulatory implications must be considered. Accountability with the HIPAA, privacy responsibilities, and acquiring appropriate authorization can result in legislative consequences (Desai & Kapadia, 2022). Telehealth for self-care management must adhere to government and federal laws regarding confidentiality, privacy of information, and informed consent. Recognizing and addressing legislative repercussions can assist in executing intervention plans (Faget et al., 2021).

New Policy Considerations

The Affordable Care Act (ACA), and Medicaid policies fulfill requirements for CHF care. This act can help implement a coordinated care intervention approach for CHF. The legislation assists in reducing medical care expenses for CHF patients by providing adequate funding and medical coverage and overcoming financial barriers (Lopez et al., 2023). Medicaid can provide cost-effective and excellent healthcare, supporting intervention plan implementation. It is estimated that around 20 million individuals are eligible for health insurance. Policies can aid CHF patient management, but paying attention to medical professionals’ education and support can hinder its effectiveness. Evaluating policy shortcomings is crucial for successfully implementing the plan (Angier et al., 2020).

Timeline

A six-month plan for CHF patients includes self-care education, treatment coordination, and drug management, involving stakeholder engagement, needs evaluations, and initial intervention strategy assessments (Santos et al., 2021). In the first two months, a needs evaluation is conducted to determine the health-promoting needs and desires of CHF patients. In the next two months, the focus will be on analyzing preliminary patient reactions by utilizing intervention approaches by various delivery mechanisms. Furthermore, end of the fourth month, evaluate the efficacy and adaptibility of the intervention plan through feedback. In the last two months, the focus has been on reviewing and refining the intervention strategy. Efforts are made for possible funding sources, addressing legislative needs, and ensuring the continued effectiveness of the intervention strategy.

Evaluation Plan

Defining Outcomes

The primary objective of the intervention strategy is to improve health promotion and the quality of life for CHF patients. Evidence-based intervention approaches, such as customized education on self-management, coordinating care, and managing medications, promote overall health (Zhao et al., 2020). The interventions predominantly target a fundamental demand for the well-being of CHF patients. Self-care education initiatives intend to mitigate the incidence of hospitalizations among CHF patients. It improves their self-management abilities and quality of living (Davis et al., 2021). Coordination of care strategies, including periodic follow-ups and patient awareness, aims to minimize complications and boost CHF patients’ safety (Ee et al., 2020). Challenges accompany CHF, and CHF patients struggle to manage complex medications. Enhanced medication management attempts to improve the medical conditions of CHF patients (D’Souza et al., 2021).

Evaluation Plan

The evaluation strategy will use an integrated strategy of both qualitative and quantitative information collection methodologies to examine the intervention’s influence on quality enhancement for adult CHF patients (Jiang et al., 2020). The plan evaluates the effects of the intervention by measuring health indicators and assessing hospitalization and admission rates. The survey approach, feedback, and interviews with CHF patients and caregivers can be utilized to evaluate the effectiveness of an educational program in improving their medical conditions (Santos et al., 2021). The intervention plan will assess CHF patients’ self-care skills through participation in health-related events like workshops, health literacy lectures, and lifestyle modification sessions (Santos et al., 2021).

The evaluation employs pre-and post-tests to examine the advancement in CHF patients’ understanding, comprehension, and perceptions of treatment before and after the intervention. The pre-test method establishes competence and awareness gaps, while the post-test evaluates change reactions to establish learning and management goals aligned with the intervention’s objectives (Jiang et al., 2020).

Discussion

Advocacy

The Nurses’ Role in Leading Change

The nurse is crucial for fostering transformation and boosting the standard and experience of adult CHF patients’ care. Nurses can effectively manage CHF patients by collaborating with other medical professionals to create personalized, integrated care plans. Nurses must coordinate on culturally competent awareness, wellness, and managing medication strategies while keeping CHF patients’ views in mind (Velarde et al., 2023). Furthermore, nurses can collaborate with patients to establish healthy practices that are necessary for self-management of diseases (Sieben et al., 2019).

Nurses significantly enhance patient safety and medical outcomes by providing self-care training, facilitating communication with medical specialists, and implementing evidence-based drug adherence techniques (Sieben et al., 2019). Nurses can work with hospital administrators and legislators to develop guidelines and rules that make it easier to implement quality improvement efforts for adult CHF patients (Blakeney et al., 2019)

Effects of the Plan on Nursing and Inter-professional Collaboration

Intervention strategies can influence nurses and interdisciplinary teamwork. Nurses must engage with medical specialists to provide effective patient care regimens, enabling multidisciplinary teamwork and cooperation (Trefethen, 2021). Healthcare workers can benefit from intervention strategies that help them communicate and collaborate more effectively. Multidisciplinary groups enhance communication and collaboration among medical providers through a patient-centered approach (Blakeney et al., 2019). Medical professionals collaborate to offer holistic care, exchange awareness on medicine management, adverse effects, and self-management, promoting improved coordination and collaboration among group members. Cooperative treatment promotes the standard of living of CHF patients (Blakeney et al., 2019).

Adopting intervention can boost the reputations of organizations and healthcare practitioners and patients’ trust in treatments based on evidence, exhibiting a dedication to quality healthcare. Utilization of these therapies reduces the rate of readmission of CHF patients. The medical organization is aided in reserving economic resources for other developmental processes (Faragli et al., 2021).

There is a need to investigate the involvement of patients and their families in the design and execution of intervention programs for CHF patients’ health promotion and quality enhancement. it is cruical to address how clinicians proactively involve patients in their healthcare procedure by acknowledging their concerns and preferences while offering personalized care. Resolving uncertainty and information shortages assists caregivers in understanding the benefits and drawbacks of applying interventions (Blakeney et al., 2019).

Future Steps

The intervention approaches can boost the life quality for adult CHF patients by making treatment options more accessible to a wide spectrum of patients. Medical staffs can improve productivity and safety by adopting telehealth tools and care approaches to boost the access of interventions (Srivastava et al., 2019). Telemedicine and wellness monitoring apps can improve the wellness outcomes of CHF patients (Woods et al., 2019). Adult patients’ health condition and outcomes can be tracked via health monitoring apps, allowing medical providers to tailor treatment plans to each individual requirements (Woods et al., 2019).

An integrated care paradigm, combining medical services and self-care, improves patient outcomes and safety. By integrating a collaborative care approach in primary care settings, it reduces the risk of adverse events, improving quality of life (Trefethen, 2021). Telehealth facilities are assumed to be accessible and effective for adult CHF patients, with medical professionals collaborative care equipped to implement integrated care models and self-management (Woods et al., 2019).

Reflection on Leading Change and Improvement

Through effective intervention tactics, the project highlights the importance of evidence-based solutions, interprofessional teamwork, and customized care in improving quality in outpatient settings (Blakeney et al., 2019). The capstone project has significantly transformed my professional and personal competency, enhancing my leadership expertise. It also emphasizes the significance of collaboration and coordination among medical disciplines. My leadership qualities have been improved and polished, resulting in a more incredible sense of accountability and devotion to standard care. My goal is to incorporate more research-based strategies into CHF care to ensure that each treatment is evidence-based. I aim to utilize interdisciplinary techniques in my practice, collaborating with practitioners from various healthcare divisions, to ensure comprehensive and effective patient care.

Integration of Intervention Insights into Broader Practice

In health setting, the comprehension of an intervention plan has substantial effectiveness for quality improvement. The plan’s emphasis on self-care and technological advances, such as telemedicine, ensures its applicability throughout various medical issues. This adaptive method includes personalized self-care education, drug adherence, centralized treatment, research-based treatment, and multidisciplinary teams’ safeguarding CHF patients and improved healthcare (Blakeney et al., 2019). By forming multidisciplinary partnership with another health professional, I will utilize this holistic approach in my practice to providing research based high-quality treatment to patients. The proposed intervention for CHF patients can function as a framework for enhancing quality procedures in a variety of medical settings.

Conclusion

The capstone project aimed to minimize CHF symptoms and improve quality of life by introducing self-care education, care coordination, and pharmacological management. Adult CHF patients can learn medication and health condition management in an outpatient setting by combining evidence-based strategies with tailored self-management support. The project’s findings can help with future therapies for CHF patients. The medical personnel involved in the intervention plan have earned essential knowledge and expertise in providing customized treatment. As a whole, the capstone project has increased health care and improved the quality of life for CHF patients.

References

Agostinho, J. R., Gonçalves, I., Rigueira, J., Aguiar-Ricardo, I., Nunes-Ferreira, A., Santos, R., Guimarães, T., Alves, P., Cunha, N., Rodrigues, T., André, Ńz., Pedro, M., Veiga, F., Pinto, F. J., & Brito, D. (2019). Protocol-based follow-up program for heart failure patients: Impact on prognosis and quality of life. Revista Portuguesa de Cardiologia, 38(11), 755–764. https://doi.org/10.1016/j.repce.2019.03.011

Alsulymani, A. S., Ashram, W., Alghamdi, A., Hafiz, H. W., Ghunaim, A. M., Aljehani, B., & Aljabri Jr, A. (2023). Risk factors for readmission in heart failure within 90 days. Cureus, 15(12). https://doi.org/10.7759%2Fcureus.50236

Angier, H., Marino, M., Springer, R., Schmidt, T., Huguet, N., & DeVoe, J. E. (2020). The Affordable care act improved health insurance coverage and cardiovascular‐related screening rates for cancer survivors seen in community health centers. Cancer, 126(14), 3303–3311. https://doi.org/10.1002/cncr.32900

Bhaskar, S., Rastogi, A., Chattu, V. K., Adisesh, A., Thomas, P., Alvarado, N., & Walker, A. H. (2020). Key strategies for clinical management and improvement of healthcare services for cardiovascular disease and diabetes patients in the coronavirus (COVID-19) settings: Recommendations from the REPROGRAM consortium. Frontiers in Cardiovascular Medicine, 7, 112. https://doi.org/10.3389/fcvm.2020.00112

Blakeney, A. E., Lavallee, D. C., Baik, D., Pambianco, S., O’Brien, K. D., & Zierler, B. K. (2019). Purposeful interprofessional team intervention improves relational coordination among advanced heart failure care teams. Journal of Interprofessional Care, 33(5), 481-489. https://doi.org/10.1080/13561820.2018.1560248

Butler, J., Petrie, M. C., Bains, M., Bawtinheimer, T., Code, J., Levitch, T., Elmas Malvolti, Monteleone, P., Stevens, P., Vafeiadou, J., & Carolyn S.P. Lam. (2023). Challenges and opportunities for increasing patient involvement in heart failure self-care programs and self-care in the post–hospital discharge period. Research Involvement and Engagement, 9(1). https://doi.org/10.1186/s40900-023-00412-x

Chun, K. H., & Kang, S. M. (2021). Cardiac rehabilitation in heart failure. International Journal of Heart Failure, 3(1), 1. https://doi.org/10.36628%2Fijhf.2020.0021

NURS FPX 6030 Assessment 6 Final Project Submission

Costa, L. L., Islam, M. S., Anowar, M. N., & Latif, M. A. (2020). Quality of life of chronic heart failure patients. Open Journal of Nursing, 10(9), 831-857. https://doi.org/10.4236/ojn.2020.109058

D’Souza, P. J., Devasia, T., Paramasivam, G., Shankar, R., Noronha, J. A., & George, L. S. (2021). Effectiveness of self‐care educational programme on clinical outcomes and self‐care behaviour among heart failure peoples—a randomized controlled trial: Study protocol. Journal of Advanced Nursing, 77(11), 4563-4573. https://doi.org/10.1111/jan.14981

Davidson, A. R., Kelly, J., Ball, L., Morgan, M., & Reidlinger, D. P. (2022). What do patients experience? Interprofessional collaborative practice for chronic conditions in primary care: An integrative review. BioMed Central Primary Care, 23(1), 1-12. https://doi.org/10.1186/s12875-021-01595-6

Davis, K. M., Eckert, M. C., Hutchinson, A., Harmon, J., Sharplin, G., Shakib, S., & Caughey, G. E. (2021). Effectiveness of nurse–led services for people with chronic disease in achieving an outcome of continuity of care at the primary-secondary healthcare interface: A quantitative systematic review. International Journal of Nursing Studies, 121, 103986. https://doi.org/10.1016/j.ijnurstu.2021.103986

Desai, M. K., & Kapadia, J. D. (2022). Medical professionalism and ethics. Journal of Pharmacology and Pharmacotherapeutics, 13(2), 113-118. https://doi.org/10.1177/0976500X221111448

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 6 Final Project Submission

Ding, H., Jayasena, R., Chen, S. H., Maiorana, A., Dowling, A., Layland, J., & Edwards, I. (2020). The effects of telemonitoring on patient compliance with self-management recommendations and outcomes of the innovative telemonitoring enhanced care program for chronic heart failure: Randomized controlled trial. Journal of Medical Internet Research, 22(7), e17559. https://doi.org/10.2196/17559

Dunlay, S. M., Givertz, M. M., Aguilar, D., Allen, L. A., Chan, M., Desai, A. S., Deswal, A., Dickson, V. V., Kosiborod, M. N., Lekavich, C. L., McCoy, R. G., Mentz, R. J., & Piña, I. L. (2019). Type 2 diabetes mellitus and heart failure: A scientific statement from the American heart association and the heart failure society of America. Circulation, 140(7). https://doi.org/10.1161/cir.0000000000000691

Ee, C., Lake, J., Firth, J., Hargraves, F., De Manincor, M., Meade, T., & Sarris, J. (2020). An integrative collaborative care model for people with mental illness and physical comorbidities. International Journal of Mental Health Systems, 14, 1-16. https://doi.org/10.1186/s13033-020-00410-6

Faget, K., Lacktman, N. M., Joseph, J., & Shalom, A. (2021). Telehealth legal and regulatory issues. Telemedicine: Overview and Application in Pulmonary, Critical Care, and Sleep Medicine, 15-31.https://doi.org/10.1007/978-3-030-64050-7_2

Faragli, A., Abawi, D., Quinn, C., Cvetkovic, M., Schlabs, T., Tahirovic, E., & Alogna, A. (2021). The role of non-invasive devices for the telemonitoring of heart failure patients. Heart Failure Reviews, 26, 1063-1080. https://doi.org/10.1007/s10741-020-09963-7

NURS FPX 6030 Assessment 6 Final Project Submission

Fedson, S., & Bozkurt, B. (2022). Telehealth in heart failure. Heart Failure Clinics, 18(2), 213-221.https://doi.org/10.1016/j.hfc.2021.12.001

Friis, K., Mathias Lasgaard, Marie Hauge Pedersen, Duncan, P., & Helle Terkildsen Maindal. (2019). Health literacy, multimorbidity, and patient-perceived treatment burden in individuals with cardiovascular disease. A Danish population-based study. Patient Education and Counseling, 102(10), 1932–1938. https://doi.org/10.1016/j.pec.2019.05.013

Goyal, P., Balkan, L., Ringel, J. B., Hummel, S. L., Sterling, M. R., Kim, S., & Levitan, E. B. (2021). The Dietary Approaches to Stop Hypertension (DASH) diet pattern and incident heart failure. Journal of Cardiac Failure, 27(5), 512-521. https://doi.org/10.1016/j.cardfail.2021.01.011

Greene, S. J., Adusumalli, S., Albert, N. M., Hauptman, P. J., Rich, M. W., Heidenreich, P. A., & Butler, J. (2021). Building a heart failure clinic: A practical guide from the heart failure society of America. Journal of Cardiac Failure, 27(1), 2-19. https://doi.org/10.1016/j.cardfail.2020.10.008

Griffin, D. S., Garcia-Cardenas, V., Williams, K., & Benrimoj, S. I. (2019). Helping patients help themselves: A systematic review of self-management support strategies in primary health care practice. PloS One, 14(8), e0220116. https://doi.org/10.1371/journal.pone.0220116

Guo, X., Gu, X., Jiang, J., Li, H., Duan, R., Zhang, Y., & Chen, F. (2019). A hospital-community-family–based telehealth program for patients with chronic heart failure: Single-arm, prospective feasibility study. JMIR mHealth and uHealth, 7(12), e13229. https://doi.org/10.2196/13229

Habibzadeh, H., Bagherzadi, A., Didarloo, A., & Khalkhali, H. (2021). The effect of patient education based on health belief model on hospital readmission preventive behaviors and readmission rate in patients with a primary diagnosis of acute coronary syndrome: A quasi-experimental study. BioMed Central Cardiovascular Disorders, 21(1), 595. https://doi.org/10.1186/s12872-021-02413-8

NURS FPX 6030 Assessment 6 Final Project Submission

Halatchev, I. G., McDonald, J. R., & Wu, W. C. (2020). A patient-centred, comprehensive model for the care for heart failure: The 360 heart failure centre. Open Heart, 7(2). https://doi.org/10.1136%2Fopenhrt-2019-001221

Heidenreich, P. A., Fonarow, G. C., Opsha, Y., Sandhu, A. T., Sweitzer, N. K., Warraich, H. J., & Ng, T. (2022). Economic issues in heart failure in the United States. Journal of Cardiac Failure, 28(3), 453-466. https://doi.org/10.1016%2Fj.cardfail.2021.12.017

Hill, L., Baruah, R., Beattie, J. M., Bistola, V., Castiello, T., Celutkienė, J., & Jaarsma, T. (2023). Culture, ethnicity, and socio‐economic status as determinants of the management of patients with advanced heart failure who need palliative care: A clinical consensus statement from the Heart Failure Association (HFA) of the ESC, the ESC patient forum, and the European association of palliative care. European Journal of Heart Failure, 25(9), 1481-1492. https://doi.org/10.1002/ejhf.2973

Hirani, S., Ambreen Gowani, Sajjad, S., Kennedy, M., & Norris, C. M. (2022). Psychosocial interventions and mental health in patients with cardiovascular diseases living in low and middle-income countries: A systematic review protocol. Plos One, 17(7), e0271955–e0271955. https://doi.org/10.1371/journal.pone.0271955

NURS FPX 6030 Assessment 6 Final Project Submission

Jaarsma, T., Hill, L., Antoni Bayés‐Genís, Hans‐Peter Brunner‐La Rocca, Castiello, T., Jelena Čelutkienė, Marqués-Sulé, E., Plymen, C. M., Piper, S., Riegel, B., Rutten, F. H., Tuvia Ben Gal, Johann Bauersachs, Andrew J.S. Coats, Ovidiu Chioncel, Lopatin, Y., Lund, L. H., Mitja Lainščak, Moura, B., & Mullens, W. (2021). Self‐care of heart failure patients: Practical management recommendations from the heart failure association of the European society of cardiology. European Journal of Heart Failure, 23(1), 157–174. https://doi.org/10.1002/ejhf.2008

Kalogirou, F., Forsyth, F., Kyriakou, M., Mantle, R., & Deaton, C. (2020). Heart failure disease management: A systematic review of effectiveness in heart failure with preserved ejection fraction. ESC Heart Failure, 7(1), 195-213. https://doi.org/10.1002/ehf2.12559

Kao, D. P., Trinkley, K. E., & Lin, C. T. (2020). Heart failure management innovation enabled by electronic health records. Heart Failure, 8(3), 223-233. https://doi.org/10.1016%2Fj.jchf.2019.09.008

Koshy, A. O., Gallivan, E. R., McGinlay, M., Straw, S., Drozd, M., Toms, A. G., & Witte, K. K. (2020). Prioritizing symptom management in the treatment of chronic heart failure. ESC Heart Failure, 7(5), 2193-2207. https://doi.org/10.1002/ehf2.12875

Koutlas, A., & Jenkins, P. (2022). Reducing hospital admissions for patients with heart failure by implementing the chronic care management framework: A cost, quality and satisfaction improvement project. The Journal of Doctoral Nursing Practice, 15(2), 96–104. https://doi.org/10.1891/jdnp-2021-0019

Kripalani, S., Chen, G., Ciampa, P. J., Theobald, C., Cao, A., McBride, M., Dittus, R. S., & Speroff, T. (2019). A transition care coordinator model reduces hospital readmissions and costs. Contemporary Clinical Trials, 81, 55–61. https://doi.org/10.1016/j.cct.2019.04.014

NURS FPX 6030 Assessment 6 Final Project Submission

Kumari, B., Kaur, S., Dutta, M., Barwad, P., & Bahl, A. (2020). Exploring the opinion of stakeholders about self-care, home care and hospital management of heart failure patients: A qualitative study. International Journal of Care Coordination, 23(4), 137-146. https://doi.org/10.1177/2053434520982224

Leavitt, M. A., Hain, D. J., Keller, K. B., & Newman, D. (2020). Testing the effect of a home health heart failure intervention on hospital readmissions, heart failure knowledge, self-care, and quality of life. Journal of Gerontological Nursing, 46(2), 32–40. https://doi.org/10.3928/00989134-20191118-01

Lopez, J. L., Duarte, G., Taylor, C. N., & Ibrahim, N. E. (2023). Achieving health equity in the care of patients with heart failure. Current Cardiology Reports, 1-13. https://doi.org/10.1007/s11886-023-01994-4

Lum, M. V., Martin, Harris, D., & Sakakibara, B. M. (2020). A scoping review of polypharmacy interventions in patients with stroke, heart disease and diabetes. International Journal of Clinical Pharmacy, 42(2), 378–392. https://doi.org/10.1007/s11096-020-01028-x

Mohebbi, B., Sabouri, M., & Tol, A. (2021). Application of health education and promotion theory-based interventions on patients with cardiovascular disease: A systematic review. Journal of Education and Health Promotion, 10. https://doi.org/10.4103%2Fjehp.jehp_173_21

Nair, L., & Adetayo, O. A. (2019). Cultural competence and ethnic diversity in healthcare. Plastic and Reconstructive Surgery – Global Open, 7(5), e2219–e2219. https://doi.org/10.1097/gox.0000000000002219

NURS FPX 6030 Assessment 6 Final Project Submission

Nasiri, M., Jafari, Z., Rakhshan, M., Yarahmadi, F., Zonoori, S., Akbari, F., & Rezaei, M. (2023). Application of Orem’s theory‐based caring programs among chronically ill adults: A systematic review and dose–response meta‐analysis. International Nursing Review, 70(1), 59-77. http://dx.doi.org/10.1111/inr.12808

Olson, M. F., Thompson, Z., Xie, L., & Nair, A. (2023). Broadening heart failure care beyond cardiology: Challenges and successes within the landscape of multidisciplinary heart failure care. Current Cardiology Reports. https://doi.org/10.1007/s11886-023-01907-5

Ozavci, G., Bucknall, T., Woodward-Kron, R., Hughes, C., Jorm, C., Joseph, K., & Manias, E. (2021). A systematic review of older patients’ experiences and perceptions of communication about managing medication across transitions of care. Research in Social and Administrative Pharmacy, 17(2), 273-291. https://doi.org/10.1016/j.sapharm.2020.03.023

Passantino, A., Adelaide, L., Ugo Corrà, Simonetta Scalvini, Massimo Pistono, Maurizio Bussotti, Fabiana Isabella Gambarin, Domenico Scrutinio, & Teresa, M. (2021). The future of exercise-based cardiac rehabilitation for patients with heart failure. Frontiers in Cardiovascular Medicine, 8. https://doi.org/10.3389/fcvm.2021.709898

Pedroni, C., Djuric, O., Bassi, M. C., Mione, L., Caleffi, D., Testa, G., & Giorgi Rossi, P. (2023). Elements characterising multicomponent interventions used to improve disease management models and clinical pathways in acute and chronic heart failure: A scoping review. Healthcare, 11(90), 1227. https://doi.org/10.3390/healthcare11091227

NURS FPX 6030 Assessment 6 Final Project Submission

Powell, C., Ismail, H., Davis, M., Taylor, A. M., Breen, L., Fylan, B., Alderson, S., Gale, C. P., Kellar, I., Silcock, J., & Alldred, D. P. (2022). Experiences of patients with heart failure with medicines at transition intervention: Findings from the process evaluation of the Improving the Safety and Continuity of Medicines management at Transitions of care (ISCOMAT) programme. Health Expectations, 25(5), 2503–2514. https://doi.org/10.1111/hex.13570

Riegel, B., Dunbar, S. B., Fitzsimons, D., Freedland, K. E., Lee, C. S., Middleton, S., Strömberg, A., Vellone, E., Webber, D. E., & Jaarsma, T. (2021). Self-care research: Where are we now? Where are we going? International Journal of Nursing Studies, 116, 103402–103402. https://doi.org/10.1016/j.ijnurstu.2019.103402

Salahodinkolah, M. K., Ganji, J., Moghadam, S. H., Shafipour, V., Jafari, H., & Salari, S. (2020). Educational intervention for improving self-care behaviors in patients with heart failure: A narrative review. Journal of Nursing and Midwifery Sciences, 7(1), 60. https://doi.org/10.4103/jnms.jnms_19_19

Santos, G. C., Liljeroos, M., Dwyer, A. A., Jaques, C., Girard, J., Strömberg, A., & Schäfer-Keller, P. (2021). Symptom perception in heart failure–Interventions and outcomes: A scoping review. International Journal of Nursing Studies, 116, 103524.https://doi.org/10.1016/j.ijnurstu.2020.103524

Sarkies, M., Long, J. C., Pomare, C., Wu, W., Clay-Williams, R., Nguyen, H. M., & Braithwaite, J. (2020). Avoiding unnecessary hospitalisation for patients with chronic conditions: Asystematic review of implementation determinants for hospital avoidance programmes. Implementation Science, 15(1), 1-17. https://doi.org/10.1186/s13012-020-01049-0

NURS FPX 6030 Assessment 6 Final Project Submission

Schumacher, P. M., Becker, N., Tsuyuki, R. T., Griese‐Mammen, N., Koshman, S. L., McDonald, M. A., & Schulz, M. (2021). The evidence for pharmacist care in outpatients with heart failure: A systematic review and meta‐analysis. ESC Heart Failure, 8(5), 3566-3576. https://doi.org/10.1002%2Fehf2.13508

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

Singhal, A., Riley, J. P., & Cowie, M. R. (2023). Benefits and challenges of telemedicine for heart failure consultations: A qualitative study. BioMed Central Health Services Research, 23(1), 847. https://doi.org/10.1186/s12913-023-09872-z

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

Srivastava, A., Do, J. M., Sales, V. L., Ly, S., & Joseph, J. (2019). Impact of patient-centred home telehealth programme on outcomes in heart failure. Journal of Telemedicine and Telecare, 25(7), 425-430. https://doi.org/10.1177/1357633X18775852

Sun, J., Zhang, Z., Ma, Y., Liu, W., & Wang, C. (2019). Application of self-care based on full-course individualized health education in patients with chronic heart failure and its influencing factors. World Journal of Clinical Cases, 7(16), 2165–2175. https://doi.org/10.12998/wjcc.v7.i16.2165

NURS FPX 6030 Assessment 6 Final Project Submission

Takeda, A., Martin, N., Taylor, R. S., & Taylor, S. (2019). Disease management interventions for heart failure. The Cochrane Library, 2019(1). https://doi.org/10.1002/14651858.cd002752.pub4

Trefethen, E. P. (2021). A literature review on the benefits for an interprofessional educational program to increase novice nurse awareness of case management in heart failure. Professional Case Management, 26(2), 70-81. https://doi.org/10.1097/NCM.0000000000000438

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

Veronese, E. T., Pomerantzeff, P. M. A., & Jatene, F. B. (2021). Improving the heart team: An interdisciplinary team and integrated practice unit. World Journal of Cardiology, 13(12), 650. https://doi.org/10.4330%2Fwjc.v13.i12.650

Woods, L. S., Duff, J., Roehrer, E., Walker, K., & Cummings, E. (2019). Patients’ experiences of using a consumer mHealth app for self-management of heart failure: mixed-methods study. JMIR Human Factors, 6(2), e13009. https://doi.org/10.2196/13009

Yang, C., Hui, Z., Zeng, D., Zhu, S., Wang, X., & Lee, D. (2021). A community-based nurse-led medication self-management intervention in the improvement of medication adherence in older patients with multimorbidity: protocol for a randomised controlled trial. BioMed Central Geriatrics, 21(1). https://doi.org/10.1186/s12877-021-02097-x

Yu, D. S. F., Li, P. W. C., Li, S. X., Smith, R. D., Yue, S. C. S., & Yan, B. P. (2022). Effectiveness and cost-effectiveness of an empowerment-based self-care education program on health outcomes among patients with heart failure: A randomized clinical trial. JAMA Network Open, 5(4), e225982-e225982.https://doi.org/10.1001/jamanetworkopen.2022.5982

Zazzara, M. B., Palmer, K., Vetrano, D. L., Carfì, A., & Graziano, O. (2021). Adverse drug reactions in older adults: A narrative review of the literature. European Geriatric Medicine, 12(12). https://doi.org/10.1007/s41999-021-00481-9

NURS FPX 6030 Assessment 6 Final Project Submission

Zhao, Q., Chen, C., Zhang, J., Ye, Y., & Fan, X. (2020). Effects of self-management interventions on heart failure: Systematic review and meta-analysis of randomized controlled trials. International Journal of Nursing Studies, 110, 103689. https://doi.org/10.1016/j.ijnurstu.2020.103689

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