NURS FPX 6614 Assessment 1 Defining a Gap in Practice

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Capella university

NURS-FPX 6614 Structure and Process in Care Coordination

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Defining a Gap in Practice: Executive Summary

Chronic Heart Failure (CHF) continues to be a leading cause of morbidity and mortality, posing ongoing challenges in patient care. One of the critical concerns is the persistently high rate of hospital readmissions due to insufficient post-discharge management and limited patient education. After a steady decline in heart disease-related deaths, 2020 saw a concerning 4.1% increase (Woodruff et al., 2022). To address these issues, this paper proposes the implementation of a nurse-led transitional care management program. This initiative aims to enhance continuity of care, support patient self-management, and lower readmission rates for adults with CHF.

The proposed nurse-led program emphasizes structured discharge planning, comprehensive patient education, and systematic follow-up care. By bridging the gap between hospital and home care, this model ensures patients receive consistent, tailored support during the vulnerable post-discharge period. The objective is to improve clinical outcomes, reduce healthcare costs, and enhance the overall patient experience for individuals managing CHF.

Clinical Priorities for a Specific Population

For adult patients living with CHF, managing symptoms, preventing complications, and minimizing hospital readmissions are fundamental care priorities. A nurse-led transitional care program aligns well with these objectives by emphasizing patient education, individualized care plans, and consistent follow-up to monitor progress and manage symptoms (Li et al., 2021b). Key factors such as a patient’s socioeconomic status, health literacy, and access to healthcare services play a crucial role in influencing outcomes. Therefore, addressing disparities in care access and tailoring interventions to meet individual needs is vital for improving quality of life and preventing avoidable hospitalizations.

One prominent information gap in current CHF management is the lack of comprehensive education on self-care strategies for patients and their families. Many patients are discharged without adequate understanding of symptom recognition, medication adherence, and lifestyle modifications. Potential solutions include integrating telehealth services and fostering stronger family involvement in the care process. Studies show that telehealth-supported care models and enhanced patient-family engagement can significantly reduce readmission rates and healthcare costs (Apery & Oremus, 2022).

Table 1 below outlines clinical priorities, existing gaps, and potential solutions for managing CHF in adult patients:

Table 1

Clinical Priorities, Identified Gaps, and Solutions for CHF Management

Clinical Priorities	Identified Gaps	Potential Solutions
Reduce hospital readmissions	Insufficient post-discharge follow-up	Nurse-led transitional care programs, telehealth interventions
Improve symptom management	Limited patient education on self-care	Enhanced discharge planning, patient-family education sessions
Enhance quality of life	Barriers due to socioeconomic disparities	Tailored care plans, community resources, increased accessibility

PICOT Question

The structured PICOT question for this practice improvement initiative is: In adults with CHF in an ambulatory care setting (P), does the employment of a nurse-led intermediate care management program (I), compared to standard discharge care (C), reduce 30-day hospital readmissions (O) within three months post-discharge (T)?

The primary gap in practice identified here is the high frequency of hospital readmissions following CHF-related hospitalizations, largely attributed to inadequate transitional care. Current discharge procedures often fail to deliver comprehensive follow-up and patient education necessary for effective self-management at home. At an organizational level, introducing a nurse-led transitional care management program could address these deficiencies by providing structured care plans, continuous patient monitoring, and accessible education resources (Apery & Oremus, 2022).

Nationally, adopting such care models has the potential to standardize post-discharge care protocols, improve patient outcomes, and reduce the financial burden on the healthcare system. Evidence supports this strategy: a study by Ledwin and Lorenz (2021) demonstrated that nurse-led care programs significantly lowered 30-day readmissions, improved medication adherence, and increased patient satisfaction. These findings underscore the importance of integrating evidence-based, nurse-led transitional care services into routine CHF management.

Potential Services and Resources

Numerous services and resources are available within the United States to support CHF patients in the community setting. Key among these are the American Heart Association’s (AHA, 2023) evidence-based guidelines and Medicare’s Chronic Care Management (CCM) services (CMS, 2024). These resources aim to strengthen discharge planning, enhance care continuity, and provide structured management plans for chronic disease patients, including those with CHF.

However, several barriers limit the effectiveness of these services. Geographic disparities, inconsistent program implementation, and patient engagement challenges persist across various healthcare systems. Ledwin and Lorenz (2021) identified uneven care protocols and limited access in rural and underserved communities as critical obstacles to optimal care coordination. Addressing these issues through improved care accessibility, telehealth integration, and patient-centered education strategies is essential for achieving equitable outcomes.

Type of Care Coordination Intervention

A nurse-led intermediate care management program represents a practical and evidence-based strategy for improving transitional care outcomes in CHF patients. This intervention integrates several key components, including detailed discharge planning, individualized patient education, and routine follow-up visits. Structured communication protocols and standardized patient handoffs enhance coordination between inpatient and outpatient care teams (Li et al., 2021b).

Technological integration, such as telehealth and electronic health records (EHR), plays a vital role in this model by facilitating continuous patient monitoring and streamlined communication. Regular telehealth check-ins can detect early signs of deterioration, while medication reconciliation processes reduce the risk of adverse drug events. Collectively, these components improve adherence, decrease preventable readmissions, and align with national best practices for managing chronic heart failure (Oskouie et al., 2023).

Summary of Nursing Diagnosis

The selected nursing diagnosis for this patient population is “ineffective self-health management”. This diagnosis reflects difficulties many CHF patients face in adhering to medication schedules, consistently monitoring symptoms, and preventing hospital readmissions. Addressing this issue requires an organized, collaborative care approach.

A nurse-led transitional care management program provides an effective solution by focusing on education, symptom tracking, medication management, and routine assessments (Li et al., 2021a). Implementing strategies such as standardized discharge instructions, telemonitoring tools, and interdisciplinary care conferences ensures that both patients and healthcare providers stay informed and actively engaged. Presenting this diagnosis and intervention plan to an interprofessional team fosters coordinated efforts, improving patient outcomes and reducing healthcare utilization (Bews et al., 2023).

Planning of Intervention and Expected Outcomes

Planning for the nurse-led transitional care management program involves a comprehensive assessment of patient needs, creation of individualized care plans, and coordination among healthcare providers. Core intervention elements include patient education on disease management, medication adherence support, and consistent symptom monitoring. Structured protocols for care transitions, including telehealth check-ins and EHR documentation, ensure continuity and timely interventions.

Expected outcomes for this program include a reduction in 30-day hospital readmissions, improved medication adherence rates, and enhanced patient engagement in self-care activities (Li et al., 2021c). The intervention also anticipates increased patient satisfaction and overall health outcomes. Assumptions for successful implementation involve the availability of telehealth resources, consistent interdisciplinary team involvement, and continuous program evaluation. Regular monitoring and adjustments will ensure the program remains effective and responsive to patient needs (Apery & Oremus, 2022).

Conclusion

In summary, implementing a nurse-led transitional care management program for CHF patients offers a viable, evidence-based strategy for addressing persistent gaps in post-discharge care. This intervention improves care coordination, enhances patient self-management, and reduces hospital readmissions. Adhering to established care coordination standards, integrating telehealth, and fostering interprofessional collaboration will support sustained improvements in patient outcomes and system efficiency.

References

AHA. (2023). American Heart Association. https://www.heart.org/

Apery, K., & Oremus, M. (2022). Efficacy of telehealth in integrated chronic disease management for older, multimorbid adults with heart failure: A systematic review. International Journal of Medical Informatics, 162, 104756. https://doi.org/10.1016/j.ijmedinf.2022.104756

NURS FPX 6614 Assessment 1 Defining a Gap in Practice

Bews, H. J., Pilkey, J. L., Malik, A. A., & Tam, J. W. (2023). Alternatives to hospitalization: Adding the patient voice to advanced heart failure management. Canadian Journal of Cardiology, 5(6), 454–462. https://doi.org/10.1016/j.cjco.2023.03.014

CMS. (2024). Manage your chronic condition. https://www.cms.gov/priorities/health-equity/c2c/manage-your-chronic-condition#:~:text=CCM%20services%20covered%20by%20Medicare

Ledwin, K. M., & Lorenz, R. (2021). The impact of nurse-led community-based models of care on hospital admission rates in heart failure patients: An integrative review. Heart & Lung, 50(5), 685–692. https://doi.org/10.1016/j.hrtlng.2021.03.079

Li, M., Yuan, L., Meng, Q., Li, Y., Tian, X., Liu, R., & Fang, J. (2021a). Effects of nurse-led transitional care interventions for patients with heart failure on healthcare utilization: A meta-analysis of randomized controlled trials. PLOS ONE, 16(12), e0261300. https://doi.org/10.1371/journal.pone.0261300

Li, Y., Fang, J., Li, M., & Luo, B. (2021b). Effect of nurse-led hospital-to-home transitional care interventions on mortality and psychosocial outcomes in adults with heart failure: A meta-analysis. European Journal of Cardiovascular Nursing, 21(4), 307–317. https://doi.org/10.1093/eurjcn/zvab105

Li, Y., Fu, M. R., Fang, J., Zheng, H., & Luo, B. (2021c). The effectiveness of transitional care interventions for adult people with heart failure on patient-centered health outcomes: A systematic review and meta-analysis including dose-response relationship. International Journal of Nursing Studies, 117, 103902. https://doi.org/10.1016/j.ijnurstu.2021.103902

NURS FPX 6614 Assessment 1 Defining a Gap in Practice

Oskouie, S., Michael, F., Whitelaw, S., Bozkurt, B., Fonarow, G. C., & H. G. C. (2023). A scoping review of heart failure transitional care quality indicators and outcomes for use in clinical care and research. European Journal of Heart Failure, 25(10), 1842–1848. https://doi.org/10.1002/ejhf.2955

Woodruff, R. C., Tong, X., Jackson, S., Loustalot, F., & Vaughan, A. S. (2022). Abstract 9853: Trends in national death rates from heart disease in the United States, 2010–2020. Circulation, 146(1). https://doi.org/10.1161/circ.146.suppl_1.9853