Heart Failure Clinic Care Plan Assignment

Heart Failure Clinic Care Plan Assignment

Question Description
Assessment Instructions
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:

Riverbend City: Insurance Issues Mission | Transcript.
Leadership Styles | Transcript.
Leadership, Theories, Models, and Styles | Transcript.
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.
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ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: Heart Failure Clinic Care Plan Assignment

 

You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.

Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.

Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.

The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.

ADDITIONAL INSTRUCTIONS FOR THE CLASS

Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality

Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes

I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
It is best to paraphrase content and cite your source.
LopesWrite Policy

For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
Late Policy

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.
As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication

Communication is so very important. There are multiple ways to communicate with me:
Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.