NURS-FPX 6614 Structure and Process in Care Coordination

Defining a Gap in Practice: Executive Summary

Chronic Heart Failure (CHF) presents significant challenges, such as high hospital readmission rates and inadequate post-discharge care. In 2020, the heart disease death rate increased by 4.1% after years of decline (Woodruff et al., 2022). This paper will focus on implementing a nurse-led transitional care management program to address these challenges.

Clinical Priorities for a Specific Population 

In adult patients with CHF, reducing hospital readmissions, managing symptoms, and improving quality of life are key priorities. A nurse-led transitional care management program addresses these by focusing on discharge planning, patient education, and follow-up care, thus reducing complications and readmissions (Li et al., 2021b). Effective care involves personalized care plans, regular monitoring, and considering socioeconomic factors and accessibility issues. Information gaps include insufficient patient education on self-management, while alternative solutions involve telehealth and enhanced patient-family engagement. This approach aims to improve patient outcomes and reduce healthcare costs (Apery & Oremus, 2022). 

PICOT Question 

The PICOT question is: In adults with CHF in an ambulatory care setting (P), does the employment of a nurse-led intermediate care management program (I), compared to typical discharge (C), decrease 30-day hospital readmissions (O) in three months post-discharge (T)? The gap in practice is high hospital readmission rates for CHF patients due to inadequate post-discharge care. Standard discharge planning needs comprehensive follow-up and patient education, leading to better self-management. At an organizational level implementing a nurse-led transitional care management program can address this by offering personalized care plans, regular follow-up, and enhanced education (Apery & Oremus, 2022).

Nationally, adopting nurse-led transitional care programs could lower healthcare costs and improve outcomes by standardizing effective post-discharge care. Studies support this approach, with Ledwin and Lorenz (2021), showing a reduction in 30-day readmissions and demonstrating improved medication adherence and patient satisfaction. This intervention is essential for improving patient results and decreasing expenses.

Potential Services and Resources

For CHF patients, resources in the United States include guidelines from the American Heart Association and Medicare’s Chronic Care Management (CCM) services (AHA, 2023; CMS, 2024). These aim to improve outcomes through enhanced discharge planning and care continuity. However, barriers such as limited access in underserved areas, inconsistent program implementation, and gaps in patient engagement persist. Ledwin and Lorenz (2021), identify geographic disparities and inconsistent care protocols as major obstacles. Addressing barriers is crucial for improving care coordination and patient outcomes.

Type of Care Coordination Intervention 

A nurse-led intermediate care management program is the most effective intervention to improve evidence-based strategy for CHF patients. This approach involves comprehensive discharge planning, personalized patient education, and regular follow-up. Practical steps include implementing structured protocols for patient handoffs, utilizing telehealth for ongoing monitoring, and ensuring medication reconciliation (Li et al., 2021b). Additionally, integrating care coordination with electronic health records can facilitate communication and track patient progress. By focusing on these areas, the program addresses gaps in post-discharge care, improves adherence, and reduces readmission rates, thereby aligning with best practices for managing CHF in adults (Oskouie et al., 2023).

Summary of Nursing Diagnosis 

The chosen nursing diagnosis for CHF patients is “ineffective self-health management,” characterized by poor medication adherence, inadequate symptom monitoring, and frequent hospital readmissions. To address this, a nurse-led transitional care management program can be implemented. This strategy involves collaborative care through regular patient education, personalized care plans, and follow-up assessments (Li et al., 2021a). For example, best practices include using standardized discharge instructions, integrating telehealth for continuous monitoring, and conducting medication reconciliation. Presenting this diagnosis and strategy to the interprofessional team, including nurses and physicians, will highlight the need for a cohesive approach. It ensures all stakeholders understand the import