NURS FPX 6614 Assessment 1 Defining a Gap in Practice
NURS FPX 6614 Assessment 1 Defining a Gap in Practice
Name
Capella university
NURS-FPX 6614 Structure and Process in Care Coordination
Prof. Name
Date
Defining a Gap in Practice: Executive Summary
Chronic Heart Failure (CHF) presents major healthcare challenges, including high hospital readmission rates and insufficient post-discharge care. The death rate from heart disease rose by 4.1% in 2020 after years of decline (Woodruff et al., 2022). This paper proposes a nurse-led transitional care management program to address these issues and improve patient outcomes.
Clinical Priorities for a Specific Population
For adult CHF patients, key priorities include reducing hospital readmissions, managing symptoms, and enhancing quality of life. A nurse-led transitional care management program helps achieve these goals by focusing on discharge planning, patient education, and follow-up care (Li et al., 2021b). Effective care involves personalized plans, routine monitoring, and addressing socioeconomic barriers. Information gaps exist in patient education on self-management, while solutions such as telehealth and improved patient-family engagement may enhance outcomes. This strategy aims to improve patient health and reduce healthcare expenses (Apery & Oremus, 2022).
PICOT Question
The study’s PICOT question is: In adults with CHF in an ambulatory care setting (P), does a nurse-led intermediate care management program (I), compared to standard discharge (C), reduce 30-day hospital readmissions (O) within three months post-discharge (T)? The practice gap involves high CHF readmission rates due to inadequate post-discharge care. Standard discharge planning lacks essential follow-up and patient education, while a nurse-led program offers tailored care, ongoing monitoring, and better education (Apery & Oremus, 2022).
Nationally, implementing these programs could reduce healthcare costs and enhance patient outcomes through standardized post-discharge care. Studies show that nurse-led interventions decrease 30-day readmissions while improving medication adherence and patient satisfaction (Ledwin & Lorenz, 2021). This intervention is crucial for optimizing patient care and reducing financial strain.
Table: Defining a Gap in Practice
| Key Aspects | Details |
|---|---|
| Potential Services and Resources | CHF patients in the U.S. benefit from resources like American Heart Association guidelines and Medicare’s Chronic Care Management (CCM) services (AHA, 2023; CMS, 2024). These improve discharge planning and care continuity. However, challenges include restricted access in underserved regions, inconsistent program execution, and limited patient engagement (Ledwin & Lorenz, 2021). Addressing these barriers is crucial for better care coordination. |
| Type of Care Coordination Intervention | A nurse-led intermediate care program effectively improves CHF patient outcomes. This approach includes structured discharge planning, personalized patient education, and follow-up. Strategies involve standardized handoff protocols, telehealth for continuous monitoring, and medication reconciliation (Li et al., 2021b). Integrating electronic health records enhances communication and patient tracking. This program bridges post-discharge care gaps, improves adherence, and reduces readmission rates (Oskouie et al., 2023). |
| Planning and Expected Outcomes | Implementing the nurse-led transitional care program involves patient needs assessment, customized care planning, and interdisciplinary coordination. Core components include patient education, symptom tracking, and medication management. Expected results are fewer 30-day readmissions, enhanced medication adherence, and better self-management (Li et al., 2021c). The intervention aligns with care coordination standards and improves overall patient satisfaction. Key assumptions include resource availability for telehealth education and team commitment. Continuous monitoring and adaptation ensure long-term success (Apery & Oremus, 2022). |
Conclusion
A nurse-led transitional care management program is essential for addressing CHF patients’ post-discharge care needs. By focusing on structured education, monitoring, and follow-up, this approach reduces readmissions, enhances patient self-management, and improves healthcare outcomes. Ongoing program evaluation and adaptation will ensure sustained success.
References
AHA. (2023). American Heart Association. 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. https://doi.org/10.1016/j.ijmedinf.2022.104756
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. www.cms.gov
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). https://doi.org/10.1371/journal.pone.0261300
NURS FPX 6614 Assessment 1 Defining a Gap in Practice
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. https://doi.org/10.1016/j.ijnurstu.2021.103902
Oskouie, S., Michael, F., Whitelaw, S., Bozkurt, B., Fonarow, G. C., & G.C, H. (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