Science Powerpoint assignment

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Nurse-Led Transitional Care for Adults with Heart Failure

Nurse-Led Transitional Care for Adults with Heart Failure

Proposed Solution

The proposed solution is a program that includes a nurse-led heart failure transitional care program that starts before discharge and ends within the first 30 days at home. The program will include education on the importance of medication adherence, daily weight monitoring, sodium and fluid management, symptom recognition, when to contact the healthcare team, and when to seek emergency care, with a focus on the patient. There is evidence that nurse-led transitional care interventions can decrease hospital readmissions for adults with heart failure for both all-cause and heart failure-specific hospital readmission (Li et al., 2021). Patient education will be done via teach-back and written materials before discharge. Each patient will then be followed up early, either by telephone or telehealth, within 48 to 72 hours of discharge, and then again over the following 30 days as per individual risk and need. The nurse will check symptoms, medication, self-care, barriers to care, and future follow-up visits and will share concerns with the appropriate provider. The nurse-led transitional care has also been linked to better self-care and psychosocial outcomes for adults with heart failure (Li et al., 2022). This solution was chosen because it directly answered the two outcomes set in the project's questions, and it was complementary to activities that nurses could include in the discharge and follow-up process.

Implementation Plan

Strategies for Approval and Organizational Support

The first thing we will need to do is to develop a baseline of the current discharge and follow-up process for adults who are hospitalized with heart failure. Medication information and recommendations for follow-up treatment, along with discharge instructions, are generally given during the patient's stay. However, the amount of education and follow-up contact depends on the unit, provider, and patient. The process will standardize these activities so that all eligible heart failure patients will be given some regular education and early nurse follow-up.

The approval will be sought from nursing leadership, heart failure or cardiology service, case management, quality improvement leadership, information technology, and other pertinent organizational committees. The project leader will share the problem, baseline readmission data, proposed workflow, expected benefits, resource requirements, and measures of assessment. The evidence that will be presented to nurse-led transitional care, which has been shown to help decrease hospital readmissions, will support the proposed change (Li et al., 2021). Leadership support will also be enhanced by showing how the intervention can be incorporated into the current role of the nurse instead of creating a completely new service. The proposal will describe the organizational advantage foreseen, such as better continuity of care, more regular patient education, and better monitoring of patients during the first weeks after discharge.

Support staff will be provided via short meetings with nurses, case managers, providers, and other parties involved. Staff will be asked to identify the barriers to workflow and proposed practical changes prior to implementation. Before implementing a patient identification and documentation process, education or a pilot study should be performed to provide information on problems with patient identification, patient education documentation, follow-up over the telephone, and communication between departments. Changes will be made based on staff feedback from the pilot before the program is expanded.

Description of Implementation

Implementation will start with developing a standardized heart failure transitional care protocol. By the bedside nurse, case manager, or assigned transitional-care nurse, eligible adults will be identified prior to discharge. The intervention will start with an individual discharge assessment and standardized education with the teach-back method. Medications, daily weight monitoring, dietary and fluid guidelines, symptoms that should be recognized, self-care behaviors, and appropriate action when symptoms become worse will be shared with patients.

The transitional-care nurse will make the initial telephone or telehealth connection within 48-72 hours of discharge. The nurse will review symptoms, medication access and adherence, daily weight, understanding of the discharge plan, follow-up appointments, and barriers to self-care during this contact. Follow-up contacts will be made during the 30-day period as per patient risk and protocol. Typically, transitional-care programs include discharge planning, patient education, medication management, symptom recognition, and follow-up after discharge. If a patient reports any of the symptoms that warrant referral, that referral will be made to the relevant service or provider as per current clinical practice. A nurse manager or project leader will be responsible for implementation, staff education, and communicating with the involved departments, as well as for monitoring compliance with the protocol.

A nurse-led transitional intervention has also been shown to have longer-term benefits associated with hospitalization outcomes after discharge (Alcoberro et al., 2023). Therefore, we will embed education and follow-up within the existing discharge process and not as a discrete process. The project leader will review the implementation regularly to ensure that the required components of the project are being completed in the same way and that workflow issues are being resolved immediately.

Resources Required

Patients and their caregivers, bedside nurses, transitional-care nurses, nurse managers, physicians, advanced practice providers, pharmacists, case managers, social workers, quality improvement staff, information technology team, and organizational leadership will be the key stakeholders. Patient and caregiver participation will be important, as successful transitional care depends on the patient using self-care behaviors at home after they leave the hospital.

Assessment materials will include a discharge readiness checklist, a heart failure knowledge pre-test and post-test, a teach-back documentation document, a symptom management assessment, and a self-care assessment. It is supportive to incorporate patient self-care measures into the assessment process due to evidence of the nurse-led hospital-to-home transitional interventions that improve self-care outcomes (Li et al., 2022). If permitted by the organization, the Care Transitions Scale for Heart Failure or a different validated heart failure self-care scale can be used. These measures will provide a baseline of knowledge and enable post-education and follow-up knowledge to be evaluated.

When using telehealth, technology requirements will encompass access to the electronic health record, telephone services, and an approved telehealth platform. A consistent template of documentation should be introduced within the electronic health record to ensure uniformity of the intervention and minimize any extra workload. Printed educational materials and symptom-management instructions for patients will be required as well.

The financial resources will be dedicated to staff time, development and printing of educational material, technology assistance, data gathering, statistical analysis, or quality improvement analysis. The staffing needs will consist primarily of one team of a designated transitional-care nurse and project leader. Education, medication management, and follow-up can be included in nurse-led transitional-care interventions across health care settings (Koontalay et al., 2024). Staff and organizational resources should then be maximized to implement the intervention as much as possible, or they should be extended.

Evaluation Plan

Methods for Evaluating Effectiveness

A structured quality-improvement methodology will be implemented to assess the success of the nurse-led transitional-care program, with results contrasted before and after the program. Adults with heart failure will be discharged during a specified time frame, with baseline data collected. The same measures will then be gathered for eligible patients receiving the intervention for transitional care. An additional comparison group receiving usual care would further strengthen the evaluation by establishing whether observed changes are attributed to the intervention or not, and not due to other related changes in practice, if there are any, which may be observed.

The primary outcome to be measured will be the percentage of patients who are re-admitted to the hospital within 30 days of their discharge for any cause. Randomized controlled trials suggest nurse-led transitional care is effective in lowering all-cause and heart failure-specific readmissions (Li et al., 2021). The secondary utilization outcomes will be heart failure-specific readmissions, emergency department visits, and possibly length of stay in the hospital. The outcomes directly relate to the proposed problem and are typically found in the electronic health record. Emergency department use will be assessed separately due to insufficient evidence that nurse-led transitional care reduced emergency department visits.

The secondary question will be assessed using the measurement of changes in patient self-care and symptom-management behaviors. The findings of nurse-led hospital-to-home transitional care show that these interventions can enhance self-care and psychosocial outcomes for adults with heart failure (Li et al., 2022). Patients will complete a validated heart failure self-care measure at baseline or prior to discharge, and at follow-up, which may be at 30 days. A brief heart failure knowledge assessment will be utilized as a pre- and post-test for the standardized education, and knowledge will also be assessed. Teach-back performance, medication adherence, daily weight monitoring, symptom recognition, and attendance at scheduled follow-up appointments will be documented as process or behavioral measures.

Implementation fidelity will also be assessed. The levels of intensity and complexity of nurse-led transitional-care interventions may have a relationship to their impact on heart failure-specific readmissions (Li et al., 2021). The project team will thus be able to identify the percentage of eligible patients who were discharged with standardized discharge education, who performed the teach-back process, and who had their first telephone or telehealth contact within the first 48-72 hours after the initial discharge, and who had the planned follow-up contacts. Monitoring fidelity is important because without the main components of the intervention, the intervention cannot be fairly evaluated. The assessment will therefore not only gauge if results have been achieved but also if the intervention has been implemented as planned.

Projected Outcomes and Variables

The primary outcome is a decrease in the 30-day all-cause readmission rate for heart failure patients receiving the nurse-led transitional-care program in comparison with those who do not receive it. Research on nurse-led transitional care positively correlates with the potential for structured care to be implemented during the transition from hospital to home to enhance other outcomes and self-care (Li et al., 2022). A secondary projected outcome is an improvement in heart failure self-care and symptom-management behaviors. Other more recent evidence has also identified discharge, self-care education, medication management, and early symptom recognition as important aspects of nurse-led transitional care (Koontalay et al., 2024). The results are directly related to the main and secondary project questions.

The independent variable will be whether patients participated in the nurse-led transitional-care program. One of the main outcomes will be the 30-day all-cause readmission. Other dependent variables will be heart failure-specific readmission, emergency department use, self-care behavior scores, symptom-management behavior scores, heart failure knowledge scores, medication adherence, daily weight monitoring adherence, follow-up appointment adherence, and patient-reported confidence in heart failure management. Patient characteristics such as sex, age, previous hospitalizations, comorbidities, social or care access barriers should also be recorded, as these might be factors that affect outcome and therefore help describe the population receiving the intervention.

Data will be analyzed periodically throughout the pilot. Baseline data should be compared to results, and trends should be reported to nursing leadership and other stakeholders. If the intervention achieves the desired readmission reduction and promotes positive self-care behaviors and implementation fidelity, then leadership should consider continuation or scaling up of the program. The results of the evaluation will not be used to change the intervention if no improvements are found, but will be used to identify deficiencies in the education, follow-up timing, participation of patients, staffing, or other aspects. This acknowledges that transitional care is a complex process and implementation is not only clinically effective but also easily integrated into the organization's process.

References

Alcoberro, L., Moliner, P., Vime, J., Jiménez-Marrero, S., Garay, A., Yun, S., Pons-Riverola, A., Ramos-Polo, R., Ras-Jiménez, M., Tajes, M., Hidalgo, E., Calero, E., Ruiz, M., José-Bazán, N., Ferre, C., Delso, C., Alcober, L., Enjuanes, C., & Comin-Colet, J. (2023). Breaking the 30-day barrier: Long-term effectiveness of a nurse-led 7-step transitional intervention program in heart failure. PLoS ONE, 18(2), e0279815. https://doi.org/10.1371/journal.pone.0279815

Koontalay, A., Samai, T., Samutalai, C., Onthuam, W., & Fonghiranrat, D. (2024). Effectiveness of nurse-led heart failure transitional care services in improving clinical outcomes and applicability to low-resource settings: A Meta-analysis. WHO South-East Asia Journal of Public Health, 13(2), 60–68. https://doi.org/10.4103/who-seajph.who-seajph_26_23

Li, M., Li, Y., Meng, Q., Li, Y., Tian, X., Liu, R., & Fang, J. (2021). 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), e0261300. https://doi.org/10.1371/journal.pone.0261300

Li, Y., Fang, J., Li, M., & Luo, B. (2021). 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