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)?

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 importance of enhancing care coordination to improve patient outcomes and reduce readmissions (Bews et al., 2023).

Planning of Intervention and Expected Outcomes

Planning the nurse-led transitional care management program involves assessing patient needs, creating personalized care plans, and coordinating with the interdisciplinary team. This includes patient education, medication management, and symptom monitoring with structured communication protocols. Expected outcomes are reduced 30-day readmission rates, improved medication adherence, and self-management (Li et al., 2021c). Adhering to care coordination standards aims to improve patient health and satisfaction. Assumptions include resource availability for telehealth patient education and active team engagement. Continuous evaluation and adaptation are essential for optimizing outcomes (Apery & Oremus, 2022).

Conclusion

Implementing a nurse-led transitional care management program for CHF patients addresses critical gaps in post-discharge care and improves outcomes. This approach, aligned with care coordination standards, reduces readmissions and enhances patient self-management. Ongoing evaluation and adaptation are essential to sustaining effective care and achieving desired results.

References