MAR-POSTER PRESENTATION
Mechy19
Manuscript.pdf
Heart Failure Management
MSN Project Manuscript Section IV-V
Chamberlain University
Advanced Nursing Role Synthesis
Date: June 5, 2024
Heart Failure Management
Executive Summary
The main goal of this project was to investigate the implementation of a comprehensive
nursing-led disease management program for heart failure patients in the elderly population in
Miami, Florida. The project was designed to find out if this intervention, as opposed to standard
care, would result in better clinical outcomes, fewer hospital readmissions, and a better quality of
life within the 8-week period. The amalgamation of literature and evidence helped to the
understanding of the current practices and interventions in the management of heart failure. The
suggested intervention, its implementation strategies, and dissemination plans were designed to
deal with the identified problem in a proper way.
Section 1: Introduction and Problem Identification
Problem Statement
Heart failure is a chronic condition that occurs when the heart does not pump enough
blood to meet the body!s needs (Groenewegen et al., 2020). This condition is the main healthcare
challenge that is mostly seen among the elderly population in Miami, Florida, involving many
hospitalizations and reduced quality of life (Zacke, 2019). Despite substantial strides in heart
failure management, it is still necessary to create specific interventions to improve results and
reduce healthcare spending. Therefore, the purpose of this project is to evaluate the efficacy of a
nursing-led disease management program targeted towards elderly heart failure patients in
Miami.
Problem Background
The heart failure management is a multidisciplinary task, taking into account the
complicated nature of the disease and its effect on the lives of the patients. The present practices
are mainly on the symptom management and the acute care interventions, thus hospital
readmissions and suboptimal outcomes are frequent. Through the introduction of a nursing-led
comprehensive disease management program for the elderly population in Miami, it is possible
to improve patient care, decrease the healthcare usage, and increase the overall quality of life.
Stakeholders
The stakeholders who are affected by this project are the elderly patients with heart
failure, their families, healthcare providers, hospitals, insurance providers, and community
organizations that are part of the healthcare delivery system. Every stakeholder group is very
important in making the proposed intervention successful and sustainable.
PICOT Question
"In elderly heart failure patients (population), does the implementation of a nursing-led
comprehensive disease management program (intervention) compared to standard care
(comparison) lead to improved clinical outcomes, reduced hospital readmissions, and enhanced
quality of life (outcome) within an 8-week timeframe (timing)?”
Section 2: Literature Support
Review of Literature
There is strong evidence from the literature that calls for initiation of comprehensive
disease management programs for elderly heart failure patients under the guidance of qualified
nurses. Disease management programs include a set of integrated health care services and
information handling with patients suffering from chronic illnesses (Seferovic et al., 2019;
Bragazzi et al., 2021). These programs are aimed at achieving a healthier and better life by
offering medical, psychosocial, and lifestyle interventions. Research shows that such initiatives
help to improve patient outcomes (Tomasoni et al., 2019). For example, a study conducted by
Jackevicius et al. (2018) reveals that such programs have a positive impact of decreasing
morbidity and mortality in patients diagnosed with heart failure. Additionally, these interventions
have been repeatedly associated with a reduced rate of readmissions to the hospital, thereby
relieving the burden on the healthcare systems and enhancing the efficiency of resource
utilization (Gingele et al., 2019; Bozkurt et al., 2021). The inclusion of dietary counseling,
exercise prescription, symptom assessment, and patient information to these programs yields for
improved patient management of heart failure symptoms with improved quality of life (Bragazzi
et al., 2021). The literature also points out that nurses play a significant role in these programs
(Arrigo et al., 2020). Nursing-led interventions employ the skills of nurses in patient teaching,
coordination, and chronic conditions, thereby emphasizing patient engagement (Arrigo et al.,
2020). This approach is also in line with the evidence which suggests that comprehensive disease
management programmes do not only improve clinical status but also increase quality of life of
elderly patients with heart failure by meeting their physical, emotional and social requirements.
Section 3: Intervention Description
Proposed Intervention
The goal is creating a nursing-led comprehensive disease management program that is
targeting the needs of the elderly heart failure patients in Miami. This program will cover
medication management, dietary counseling, exercise regimens, symptom monitoring and patient
education with nurses stepping into the lead role in its implementation and supervision.
Setting
The project will be conducted in health facilities that serve the elderly population in
Miami, with the goal of creating an organizational culture that supports the change of evidence-
based practice. The readiness to change in these environments will be checked to make sure the
intervention is implemented successfully. Assessing the readiness for change in these settings
will ensure the successful implementation of the intervention.
Barriers
The obstacles to the project are the resistance to change among healthcare providers, the
scarcity of resources, and the difficulties in patient adherence to the program. The ways of
coping with these problems are staff education, stakeholder engagement, and the use of the
community resources to help patients' needs. Addressing these obstacles will involve
comprehensive staff education, active stakeholder engagement, and leveraging community
resources to meet patient needs.
Outcomes
The expected results of the intervention are a reduction of hospital readmissions, the
enhancement of the symptom management, the increased patient satisfaction, and the better
adherence to the treatment regimens. The results will be measured by observing the clinical
indicators, patient-reported outcomes, and healthcare utilization metrics.
Action Plan
The action plan defines the nursing-led disease management program to be phase
implemented with nurses as the core actors of the program whose role is to teach patients,
monitor their symptoms and coordinate their care. The first step is conducting a thorough needs
assessment to identify specific gaps in the current heart failure management practices. This will
be followed by developing detailed protocols and guidelines tailored to the needs of the elderly
heart failure patients. Staff education will play a crucial role, involving comprehensive training
sessions to familiarize the healthcare providers with the new protocols and ensure they have the
necessary skills to implement the program. Collaborating with multidisciplinary teams, including
cardiologists, dietitians, and physical therapists, will be essential to provide holistic care. The
program will be introduced as a specific protocol within the health facilities, with clear
documentation and monitoring processes to track progress and outcomes. Engagement with
community resources and organizations will also be crucial to support patient adherence and
provide additional resources.
Section 4: John Hopkins Nursing Model of Evidence-Based Practice
Introduction to Model
The Johns Hopkins Nursing Evidence-Based Practice Model is the core model applied to
this project. It offers a framework for the systematic process of translating the practice changes
into intervention based on the best available evidence (Dang et al., 2021; (Dang & Dearholt,
2018). The model comprises of twenty steps that enhance the change from evidence synthesis to
practice implementation. The model will be adopted systematically through the entire project
from problem definition to assessment and implementation. It embraces the culture of getting
evidence that supports practice change and also guarantees sustainability and expansion of the
intervention (Dang & Dearholt, 2018).
Beginning with the identification of opportunities for change, the project delves into
recognizing areas within current practices that necessitate improvement. For instance, in this
project, the focus is on establishing a comprehensive disease management program for elderly
heart failure patients in Miami. Following the identification of the opportunity for change, the
scope of the project and the stakeholders involved are defined. This involves outlining the
project's boundaries and identifying key individuals and groups, including healthcare providers,
administrators, patients, and community resources crucial for the success of the program.
Subsequently, an interdisciplinary team is assembled, ensuring diverse expertise is integrated to
facilitate holistic care delivery. This multidisciplinary team includes professionals such as nurses,
cardiologists, dietitians, and physical therapists.
A pivotal step in the process involves formulating a clinical question in PICOT format,
which serves as a guiding framework for evidence gathering. This question aids in directing the
search for evidence pertinent to the project's goals. For instance, inquiring about the impact of a
nursing-led disease management program on hospital readmission rates among elderly heart
failure patients in Miami sets a clear direction for evidence collection. Thorough literature
review and evidence collection are conducted to gather data supporting the effectiveness of
nursing-led interventions in heart failure management. The collected evidence is then critically
appraised to assess its validity and relevance. Integration of evidence with clinical expertise and
patient preferences follows, culminating in the development of tailored protocols and guidelines
for the intervention.
Based on synthesized evidence, practice recommendations and guidelines for the nursing-
led disease management program are developed. A detailed implementation plan is devised,
outlining steps for introducing the program into healthcare facilities serving the target
population. This plan includes aspects such as staff education, patient recruitment, and
monitoring mechanisms.
Following implementation, key outcomes such as hospital readmission rates, symptom
severity scores, and patient satisfaction are evaluated to measure the intervention's effectiveness.
Successful practices are integrated into routine care processes, with mechanisms established to
sustain the intervention's impact. Project findings are disseminated to stakeholders through
various channels, promoting awareness and knowledge dissemination.
The project also entails implementing evidence-based practice changes derived from the
findings in healthcare settings to improve patient outcomes. Institutional mechanisms are
established to ensure the continued integration of evidence-based practices into routine care
delivery. Ongoing monitoring and evaluation of implemented changes are conducted to identify
areas for improvement and ensure sustained effectiveness.
Furthermore, changes in policies and procedures necessary to support evidence-based
practices are implemented and integrated into organizational protocols. Project outcomes are
disseminated to stakeholders to garner support and promote further adoption of evidence-based
practices. The impact of evidence-based practice changes on patient outcomes, such as improved
symptom management and reduced hospital readmissions, is evaluated.
Lastly, strategies for sustaining evidence-based practice changes are implemented,
including ongoing education, training, and quality improvement initiatives. This comprehensive
approach ensures the continuous improvement of healthcare delivery, with a focus on evidence-
based practices tailored to meet the needs of the target population.
Apply Model to Support Project
The model will be in every phase of the project, from problem identification to
evaluation and dissemination. It promotes a systematic way of evidence-based practice change
which in turn, results in the sustainability and scalability of the intervention.
Section 5: Implementation
To address the feedback and enhance the implementation section, a comprehensive plan
is outlined for implementing the nursing-led comprehensive disease management program.
Firstly, a needs assessment will be conducted, evaluating current heart failure management
practices in healthcare facilities catering to elderly patients in Miami, identifying gaps in
medication management, dietary counseling, and patient education. Subsequently, detailed
protocols and guidelines will be developed, integrating evidence-based practices and clinical
guidelines. Comprehensive training sessions will be conducted for healthcare providers to ensure
familiarity with protocols and necessary skills for implementation. Collaboration with
multidisciplinary teams, including cardiologists, dietitians, and physical therapists, will be
established to provide holistic care, fostering clear communication channels and protocols. The
program will be introduced within healthcare facilities as a specific protocol, accompanied by
clear documentation and monitoring processes. Eligible elderly heart failure patients will be
identified for enrollment, obtaining informed consent and ensuring understanding of roles and
responsibilities. Regular symptom monitoring will be implemented, with designated nurses
coordinating patient care and follow-up appointments. Engagement with community resources
and stakeholders will support patient adherence and enhance program sustainability. Continuous
evaluation will monitor program effectiveness through clinical indicators, patient-reported
outcomes, and healthcare utilization metrics, with ongoing quality improvement initiatives
implemented as needed. Project outcomes will be disseminated to stakeholders through
presentations, publications, and community forums, with sustainability plans developed to ensure
ongoing success beyond the project period. This detailed implementation plan aims to effectively
improve outcomes for elderly heart failure patients in Miami.
SECTION 6: TRANSLATION TO PRACTICE AND EVALUATION
Data Collection to Support Outcomes
The baseline data collection will tell us about the current situation of heart failure
treatment in the target population, which will help to plan and evaluate the implementation and
evaluation phases of the project. The data sources are the internal records, patient surveys, and
healthcare utilization data.
Evaluation
The evaluation of the implementation's effectiveness will be centered on key measurable
outcomes, such as hospital readmission rates, symptom severity scores, and patient satisfaction
surveys, while highlighting the influence of the nursing-led actions on the healthcare system and
patient outcomes. This will highlight the impact of nursing-led actions on the healthcare system
and patient outcomes.
Dissemination
The project results will be disseminated by means of sharing the findings with the
stakeholders through presentations, publications, and community forums. The sustainability
plans will be created to guarantee the ongoing success of the intervention even after the project
period.
Conclusions and Contributions to the Profession of Nursing
The project adds to the scientific knowledge by showing the effectiveness of a whole
disease management program in the improvement of elderly heart failure patients' outcomes. The
conclusions drawn from the project findings will be the basis for future practice and research on
heart failure management, thus, improving the quality of nursing care.
References
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Burden of heart failure and underlying causes in 195 countries and territories from 1990
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