Scenario:

The hospital where you work is experiencing a rise in readmissions within 30 days of discharge. Following an examination of the core measures, it was discovered that heart failure was the most common core measure disease process with the highest rate of readmissions. Your team has been tasked by the leadership team with developing a nurse-run outpatient heart failure clinic. The goal of this clinic is to ensure that discharge education is delivered to patients in a systematic, consistent manner that adheres to evidence-based practice protocols. Because these patients may be discharged from various areas throughout the facility, having the heart failure clinic staff take ownership of the process will improve consistency and compliance. There are cardiologists who interact with staff and patients, but the day-to-day operations of the clinic are designed and supported by nurses who interact with appropriate members of the other health care team disciplines to promote the best care for heart failure patients.

You have been tasked as a member of the nurse team with developing one aspect of the clinic.

The hospital administration established the following goals for clinic services:

Evaluate and optimize medication therapy.
Patients should attend regular diet, exercise, and stress management classes.
Keep track of the patients’ physiological indicators (lab work, weights, vital signs, ECGs).
Provide a case management system for patients who are still enrolled in the program after they have been discharged.
The overall objectives of the heart failure clinic are as follows:

Enroll more than 90% of patients with a primary or secondary diagnosis of HF before discharge.
Facilitate discharge planning in order to achieve 100 percent patient education compliance prior to discharge (discharge planning).
Reduce readmission rates in this population by 5% in the coming year.
The leadership team has requested that you provide them with an evidence-based plan for one of the clinic’s components. To convey information clearly and succinctly, you may use any combination of documents (for example, a spreadsheet or a table) in addition to explanatory information.

Create one of the following plans: an Orientation Course Plan, a Discharge Education Plan, or a Care Coordination Plan.

A Course Plan for Orientation:

Create an evidence-based health-care delivery strategy.
Include a detailed schedule of the orientation course’s topics, objectives, key points, and patient resources.
What constitutes an evidence-based education plan?
How will you know if the patients understand what you want them to do?
What methods will you employ to disseminate information?
How will you modify the plan to meet the needs of patients with varying cultural and linguistic backgrounds?
Determine your specialized and supplementary material requirements.
In support of a care plan, use professional and legal standards.
Explain how the latest Heart Failure Guidelines and specific professional standards are aligned.
Describe the accountability tools and procedures that will be used to assess effectiveness.
How will you know if the patient education program is a success?
What are the signs of success or effectiveness?
A Plan for Post-Discharge Education:

Create an evidence-based health-care delivery strategy.
Create a discharge plan with objectives and resources, as well as tools for patients to track their progress.
How will you know if the patients understand what you want them to do?
What methods will you employ to disseminate information?
How will you modify the plan to meet the needs of patients with varying cultural and linguistic backgrounds?
In support of a care plan, use professional and legal standards.
Explain how the latest Heart Failure Guidelines and specific professional standards are aligned.
Describe the accountability tools and procedures that are used to assess effectiveness.
How will you know if the discharge plan worked?
What are the signs of success or effectiveness?
Care Coordination Strategy:

Create an evidence-based health-care delivery strategy.
Create a service coordination procedure.
Consider the requirements of “outliers.” Someone suffering from lung disease, for example, may require additional resources.
Who should be a part of the team?
When would the team be put into action?
How would it be turned on?
What is the time frame for service coordination?
How would the effectiveness of the intervention plan be assessed?
In support of a care plan, use professional standards.
Explain how the latest heart failure guidelines and specific professional standards are aligned.
Describe the accountability tools and procedures that are used to assess effectiveness.
How will you know if the care coordination strategy is effective?
What are the signs of success or effectiveness?
How will information be gathered and disseminated?