Heart Failure Clinic Care Plan Scoring Guide
Deliverable: Develop an evidence-based plan for health care delivery.
Scenario:
The hospital where you work has an issue with increased readmissions within 30 days of discharge. After examining the core measures, it was found that heart failure was the most common core measure disease process experiencing the highest rate of readmissions. The leadership team has given your team the charge of developing a nurse-run outpatient heart failure clinic. The purpose of this clinic is to ensure that discharge education is presented to the patient in an orderly, consistent manner and complies with evidence-based practice protocols. Since these patients may be discharged from a variety of areas in the facility, having the heart failure clinic staff take ownership of the process will improve both consistency and compliance. There are cardiologists that interact with the staff and patients, but the day-to-day operations of the clinic are designed and supported by the nurses as they interact with appropriate members of the other health care team disciplines promoting the best care for the heart failure patients.
As a member of the nurse team, you have been asked to develop one component of the clinic.
The hospital leadership established these objectives for the clinic services:
Evaluate and maximize proper medication therapy.
Conduct regular diet, exercise, and stress management classes for the patients.
Monitor physiological indicators for the patients (lab work, weights, vital signs, ECGs).
Provide a case management system for patients in the program post-discharge.
The overall goals for the heart failure clinic are to:
Enroll greater than 90 percent of the patients with a primary or secondary diagnosis of HF prior to discharge.
Facilitate discharge planning to achieve 100 percent compliance with patient education prior to discharge (discharge planning).
Decrease readmission rates in this population by 5 percent over the next year.
The leadership team has asked you to provide them with an evidence-based plan for one of the components of the clinic. You may use any combination of documents (for example, a spreadsheet or a table) in addition to explanatory information to convey information clearly and succinctly.
Develop one: an Orientation Course Plan, a Discharge Education Plan, or a Care Coordination Plan.
An Orientation Course Plan:
Develop an evidence-based plan for health care delivery.
Include a comprehensive schedule of topics, objectives, key points, and patient resources for the orientation course.
What are the components of an evidence-based education plan?
How will you know that patients will understand what to do?
What modalities will you use to deliver information?
How will you adapt the plan to meet the needs of patients from diverse cultural and language backgrounds?
Identify specialized and supplementary material needs.
Apply professional and legal standards in support of a care plan.
Explain the alignment to the most recent Heart Failure Guidelines and specific professional standards.
Describe the accountability tools and procedures used to measure effectiveness.
How will you know if the patient education plan is successful?
What are the indicators of success or effectiveness?
A Discharge Education Plan:
Develop an evidence-based plan for health care delivery.
Develop a discharge plan with objectives and resources, and tools for patients to monitor their progress.
How will you know that patients understand what to do?
What modalities will you use to deliver information?
How will you adapt the plan to meet the needs of patients from diverse cultural and language backgrounds?
Apply professional and legal standards in support of a care plan.
Explain the alignment to the most recent Heart Failure Guidelines and specific professional standards.
Describe accountability tools and procedures used to measure effectiveness.
How will you know if the discharge plan is successful?
What are the indicators of success or effectiveness?
Care Coordination Plan:
Develop an evidence-based plan for health care delivery.
Develop a procedure for coordinating services.
Consider the needs of \”outliers.\” For example, someone with lung disease may need extra resources.
Who should be on the team?
When would the team be activated?
How would it be activated?
What is the time frame required to coordinate services?
How would the intervention plan be monitored for effectiveness?
Apply professional standards in support of a care plan.
Explain the alignment to the most recent heart failure guidelines and specific professional standards.
Describe accountability tools and procedures used to measure effectiveness.
How will you know if the care coordination plan is successful?
What are the indicators of success or effectiveness?
How will information be collected or communicated?
Additional Requirements
Written communication: Written communication should be free of errors that detract from the overall message.
APA formatting: Resources and in-text citations should be formatted according to current APA style and formatting.
Length: The report should be 3-4 pages in content length, double-spaced.
Font and font size: Times New Roman, 12 point.
Number of resources: Support your plan with a minimum of three peer-reviewed resources, in addition to professional standards.
Questions to Consider
To deepen your understanding, you are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community.
What factors contribute to inadequate quality of care?
How effective are organizational mandates for quality?
How do financial concerns impact health and safety goals?
Context
In an effort to improve the patients\’ health literacy concerning heart failure, it is important that the clinic staff and the hospital staff present a consistent, evidence-based message on self-care to these patients and their families in order to decrease acute exacerbation and re-admissions. Review current evidence for clinical practice guides or protocols when developing your patient teaching plans and materials. Consider the following:
What does the patient know about the disease process as a baseline?
What does the patient need to do understand as far as the best self-care processes?
Can the patient identify proper medication compliance?
Is there a financial issue that affects compliance?
Who buys and prepares the food in the home?
Can the patient verbalize when to seek medical assistance?
Overview
Write a 3-4 page evidence-based health care delivery plan for one component of a heart failure clinic.
Nursing within an organization is a critical component of health care delivery and is an essential ingredient in patient outcomes (Kelly & Tazbir, 2014). The concern for quality care that flows from evidence-based practice generates a desired outcome. Without these factors, a nurse cannot be an effective leader. It is important to lead not only from this position but from knowledge and expertise.
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By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
Competency 2: Explain the accountability of the nurse leader for decisions that affect health care delivery and patient outcomes.
Describe accountability tools and procedures used to measure effectiveness.
Competency 3: Apply management strategies and best practices for health care finance, human resources, and materials allocation decisions to improve health care delivery and patient outcomes.
Develop an evidence-based plan for health care delivery.
Competency 4: Apply professional standards of moral, ethical, and legal conduct in professional practice.
Apply professional and legal standards in support of a care plan.
Competency 5: Communicate in manner that is consistent with the expectations of a nursing professional.
Write content clearly and logically, with correct use of grammar, punctuation, and mechanics.
Correctly format citations and references using current APA style
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