Task: Heart Failure Clinic Care Plan

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PREPARATION

Refer to the Capella library and the Internet for supplemental resources to help you complete this assessment.

INSTRUCTIONS

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.

Library Resources

Capella Multimedia

Click the links provided below to view the following multimedia pieces:

The following resources are provided for you in the Capella University Library and are linked directly in this course. These articles contain content relevant to the topics and assessments that are the focus of this unit.

Mensik, J. S. (2013). Nursing’s role and staffing in accountable care. Nursing Economics, 31(5), 250–253.
Ganz, F. D., Wagner, N., & Toren, O. (2015). Nurse middle manager ethical dilemmas and moral distress. Nursing Ethics, 22(1), 43–51.
Ott, J., & Ross, C. (2014). The journey toward shared governance: The lived experience of nurse managers and staff nurses. Journal of Nursing Management, 22(6), 761–768.
Tait, G. R., Bates, J., LaDonna, K. A., Schulz, V. N., Strachan, P. H., McDougall, A., & Lingard, L. (2015). Adaptive practices in heart failure care teams: Implications for patient-centered care in the context of complexity. Journal of Multidisciplinary Healthcare, 8, 365–376.
Boyde, M., Song, S., Peters, R., Turner, C., Thompson, D. R., & Stewart, S. (2013). Pilot testing of a self-care education intervention for patients with heart failure. European Journal of Cardiovascular Nursing, 12(1), 39–46.
Brennan, E. J. (2015). Heart failure care for patients who do not speak English. British Journal of Nursing, 24(20), 1004–1008.
Coordinating the medical home for heart failure patients; transitioning to palliative care: Adjusting locus of care and focusing on integrated medicine sheds light on best practices and patient-centered care in heart failure clinics. (2010, September 15). PR Newswire.
Ivany, E., & While, A. (2013). Understanding the palliative care needs of heart failure patients. British Journal of Community Nursing, 18(9), 441–445.
Limpahan, L. P., Baier, R. R., Gravenstein, S., Liebmann, O., & Gardner, R. L. (2013). Closing the loop: Best practices for cross-setting communication at ED discharge. American Journal of Emergency Medicine, 31(9), 1297–1301.
Lingle, C. L. (2013). Evidence based practice: Patient discharge education barriers to patient education(Master’s thesis). Available from ProQuest Dissertation Publishing. (UMI No. 1542582)
Delaney, C., Apostolidis, B., Bartos, S., Morrison, H., Smith, L., & Fortinsky, R. (2013). A randomized trial of telemonitoring and self-care education in heart failure patients following home care discharge.Home Health Care Management and Practice, 25(5), 187–195.
Wolfson, B. J., & Campbell, R. (2014, February 9). With Medicare watching, hospitals make changes: Orange County medical centers put new focus on discharge practices to reduce patient readmissions. Orange County Register.
Berry, L. L., Rock, B. L., Houskamp, B. S., Brueggeman, J., & Tucker, L. (2013). Care coordination for patients with complex health profiles in inpatient and outpatient settings. Mayo Clinic Proceedings, 88(2), 184–194.
Veenstra, W., op den Buijs, J., Pauws, S., Westerterp, M., & Nagelsmit, M. (2015). Clinical effects of an optimised care program with telehealth in heart failure patients in a community hospital in the Netherlands. Netherlands Heart Journal, 23(6), 334–340.
Aller, M., Vargas, I., Coderch, J., Calero, S., Cots, F., Abizanda, M., … Vázquez, M. L. (2015). Development and testing of indicators to measure coordination of clinical information and management across levels of care. BMC Health Services Research, 15(323), 1–16.

Course Library Guide

A Capella University library guide has been created specifically for your use in this course. You are encouraged to refer to the resources in the BSN-FP4012 – Nursing Leadership and Management Library Guide to help direct your research.

Internet Resources

National Council of State Boards of Nursing (NCSBN). (n.d.). Retrieved from https://www.ncsbn.org/index.htm
American Nurses Association (ANA). (2015). Code of ethics for nurses. Retrieved from http://www.nursingworld.org/MainMenuCategories/Eth…

Bookstore Resources

The resources listed below are relevant to the topics and assessments in this course. Unless noted otherwise, these materials are available for purchase from the Capella University Bookstore. When searching the bookstore, be sure to look for the Course ID with the specific –FP (FlexPath) course designation.

Kelly, P., & Tazbir, J. (2014). Essentials of nursing leadership and management (3rd ed.). Clifton Park, NY: Delmar.
- Chapter 2.
- Chapters 11–15.

Task: Heart Failure Clinic Care Plan

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9/26/2018 https://courserooma.capella.edu/bbcswebdav/institution/BSN-FP/BSN-FP4012/160101/Scoring_Guides/u03a1_scoring_guide.html Heart Failure Clinic Care Plan Scoring Guide CRITERIA NON-PERFORMANCE BASIC PROFICIENT DISTINGUISHED Develop an evidence-based plan for health care delivery. Does not develop an evidence-based plan for health care delivery. Develops a plan for health care delivery, but does not provide support from best practices or current literature. Develops an evidencebased plan for health care delivery. Develops an evidencebased plan for health care delivery; identifies ways in which the interprofessional team functions. Describe accountability tools and procedures used to measure effectiveness. Does not describe accountability tools and procedures used to measure effectiveness. Identifies accountability tools but not the procedures used to measure effectiveness. Describes accountability tools and procedures used to measure effectiveness. Describes accountability tools and procedures used to measure effectiveness; suggests procedures be developed in conjunction with the interprofessional team. Apply professional and legal standards in support of a care plan. Does not apply professional and legal standards in support of a care plan. Identifies legal standards, but does not explain the professional standards in support of a care plan. Applies professional and legal standards in support of a care plan. Applies professional and legal standards in support of a care plan; explains how standards provide the structure for care delivery. Write content clearly and logically, with correct use of grammar, punctuation, and mechanics. Does not write content clearly or logically, with correct use of grammar, punctuation, and mechanics. Writes with errors in clarity, logic, grammar, punctuation, or mechanics. Writes content clearly and logically, with correct use of grammar, punctuation, and mechanics. Task: Heart Failure Clinic Care Plan

Writes clearly and logically, with correct use of spelling, grammar, punctuation, and mechanics; uses relevant evidence to support a central idea. Correctly format citations and references using current APA style. Does not correctly format citations and references using current APA style. Uses current APA to format citations and references but with numerous errors. Correctly formats citations and references using current APA style with few errors. Correctly formats citations and references using current APA style with no errors. https://courserooma.capella.edu/bbcswebdav/institution/BSN-FP/BSN-FP4012/160101/Scoring_Guides/u03a1_scoring_guide.html 1/1 9/26/2018 Leadership, Theories, Models and Styles Leadership, Theories, Models and Styles Theory Definition Can be tested and is used to explain construct(s) under investigation. Attempts to explain leadership and the consequences of leadership. Purpose Leadership theories build on previous research to understand different leadership constructs. Theories are used to research leadership behaviors. Example Charismatic theory. Transformational theory. Visionary theory. Trait theories. Model Definition Shows/illustrates the interaction among leadership variables. Purpose Models put theories into action. Task: Heart Failure Clinic Care Plan

They illustrate how leadership theories can be applied in different settings. Example Warrior Model of Leadership. Rational-Deductive Model. Style of Leadership Definition Approach to providing leadership. Purpose Styles focus on what leaders are doing. Example Participative (Democratic). Authoritarian (Autocratic) http://media.capella.edu/CourseMedia/psy8720/LeadershipTheoriesModelsStyles/illustration_wrapper.asp 1/2 9/26/2018 Leadership, Theories, Models and Styles Typology Definition Describes different types of leaders. Purpose Leadership types provide information on the commonalities and differences when describing leadership behaviors. Example Static leaders. Executive leaders. Professional leaders. Group leaders  Was this media helpful? Licensed under a Creative Commons Attribution 3.0 License.